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http://www.archive.org/details/systemofsurgery01denn 


/ 


LIST   OF   AUTHORS  IN  VOL.  I. 


BIGGS,  HERMANN    M,,  M.  D. ; 
BILLINGS,  JOHN   S.,  M.  D.,  LL.D.; 
CARMALT,  WILLIAM    H.,  M.  D.  ; 
CONNER,  PHINEAS   S.,  M.  D.; 
COUNCILMAN,  WILLIAM   T.,  M.  D. 
DENNIS,  FREDERIC   S.,  M.D.; 
GERSTER,    A.  G.,  M.D.; 
NANCREDE,  CHARLES   B.,  M.  D. ; 
SMITH,   STEPHEN,  M.D.; 
WARREN,  J.  COLLINS,  M.D.; 
WELCH,  WILLIAM   H.,  M.D.; 
WOOD,  HORATIO  C,  M.  D. 


SYSTEM 


OP 


SURGERY. 


EDITED  BY 

FREDERIC  S.  DENNIS,  M.D., 
/ 

Professor  of  the  Principles  and  Practice  op  surgery,  Bei.levue  Hospital  Medical  College; 

Visiting  Surgeon  to  the  Bellevue  and  St.  Vincent  Hospitals  ;  Consulting  Surgeon  to 

the  Harlem  Hospital  and  the  Montefiore  Ho.aie,  New  York;  President  of 

the  American  Surgical  Society  ;  Graduate  of  the  Royal  College 

OF  Surgeons,  London  ;  Member  of  the  German 

Congress  op  Surgeons,  Berlin. 


ASSISTED   BY 

JOHN   S.  BILLINGS,  M.  D.; 

LL.D.  Edin.  and  Harv.  ;  D.  C.  L.  OxoN. ;  Deputy  Surgeon-general  U.  S.  A. 


Vol.  I. 


THE  HISTORY  OF  SURGERY-PATHOLOGY-BACTERIOLOGY- 

INFEOTIONS -ANAESTHESIA- FRACTURES  AND 

DISLOCATIONS-OPERATIVE  SURGERY. 


PROFUSELY  ILLUSTRATED. 


PHILADELPHIA: 
LEA    BROTHERS    &   CO. 

1895. 


<  ! 

h  / 


Entered  according  to  Act  of  Congress  in  the  year  1895,  by 

LEA    BROTHERS   &   CO., 

in  the  Office  oi"  the  Librarian  of  Congress,  at  Washington.     All  rir^hts  reserved. 


WESTCOTT    &    THOMSON. 
ELECTROTYPERS,     PHILADA. 


WILLIAM    J.    DORNAN. 
PRINTER,  PHILADA. 


PREFACE. 


This  System  of  Surgery  is  intended  to  meet  a  growing  want  created 
by  the  great  progress  which  Surgery  has  made  during  the  past  few 
years.  It  is  with  a  view  to  i'ulfil  this  object  tliat  men  of  recognized 
authority  in  their  respective  branches  have  consented  to  contribute  in 
order  to  present  to  the  profession  a  comjilcte  review  of  the  domain  of 
modern  Surgery — a  domain  whicli  has  so  wonderfully  enlarged  its  bound- 
aries through  the  achievements  rendered  possible  by  the  systematic 
employment  of  antiseptic  and  aseptic  methods  of  procedure.  The  task 
has  been  most  onerous,  but  the  labors  of  an  eminent  corps  of  contribu- 
tors have  enabled  the  Editor  to  oiFer  to  the  profession  a  concise  and 
complete  work,  presenting  the  most  advanced  opinions  upon  the  new 
problems  involved  in  modern  surgery,  as  well  as  the  practical  details 
which  conduce  to  success  in  treatment.  In  accomplishing  this  it  is 
gratifying  to  be  able  to  announce  that  the  whole  has  been  the  work 
of  American  surgeons,  and  that  it  may  be  fairly  said  to  represent  the 
most  advanced  condition  of  American  Surgery. 

The  Editor  takes  this  occasion  to  acknowledge  his  obligations  to  the 
contributors,  each  one  of  whom  is  a  teacher  of  Surgery  or  a  director  in 
some  large  surgical  clinic  or  hospital,  and  who,  for  this  reason,  is  capable 
of  speaking  with  clinical  authority  from  an  experience  based  on  the 
study  and  observation  of  a  large  number  of  cases.  Each  department 
is  thus  treated  by  an  acknowledged  master  of  the  subject,  who  is  able  to 
present  the  most  modern  and  advanced  views  in  the  most  cogent  and 
demonstrative  way. 

The  Editor  trusts  that  he  will  be  found  to  have  succeeded  in  the 
endeavor  to  present  a  work  of  the  scope  and  breadth  that  this  great 
subject  demands,  and  that  an  appreciative  reception  will  be  accorded  to 
the  results  given  by  the  contributors,  who,  though  busy  men,  have  con- 
sented to  offer  the  fruits  of  their  labors  for  the  benefit  of  the  medical 
profession. 

The  Editor  especially,  desires  to  acknowledge,  with  sincere  thanks, 
the  great  assistance  accoi'ded  to  him  by  Dr.  John  S.  Billings,  through 
whose  valuable  services  and  co-operation  he  has  been  enabled  to  bring 
before  the  profession  this  work  in  its  present  comprehensive  and  at 
the  same  time  compact  form. 

Xo.  .542  Madisos  Avenue,  New  Yoek. 
March,  1895. 

5 


CONTENTS  OF  VOLUME  I. 


PACE 

THE  HISTORY  AND  LITEBATURE  OF  SURGERY 17 

By  John  S.  Billings,  M.  D.,  LL.D.,  Edinburgh  and  Harvard ;  D.  C.  L.  Oxon. ; 
Deputy  Surgeon-general,  U.  S.  A. 

SURGICAL    PATHOLOGY',    INCLUDING    INFLAMilATION    AND    THE 

REPAIR  OF  WOUNDS 145 

By  WiLLL\:vt  T.  Councilman,  iM.  D.,  Professor  of  Pathology,  Harvai-d  Med- 
ical School,  Boston. 

GENERAL  BACTERIOLOGY  OF  SURGICAL  INFECTIONS 249 

By  William  H.  Welch,  M.  D.,  Professor  of  Pathology,  Johns  Hopkins 
University,  Baltimore. 

SYMPTOMS,     DIAGNOSIS,    AND    TREATMENT    OF    INFLA]MMATION, 

ABSCESS,  ULCER,  AND  GAN(4RENE      .S35 

By  Charle-s  B.  Nanceede,  A.  M.,  M.  1 ).,  Professor  of  Surgery  and  of  Clinical 
Surgery,  jNIedical  Department  of  the  I'niversity  of  Michigan,  Ann  Arlior. 

SEPTICEMIA,  PY45MIA,  AND  POISONED  WOUNDS 383 

By  William  H.  Carmalt,  M.  D.,  Profes.sor  of  Surgery,  Department  of 
Medicine,  Y'ale  University,  New  Haven. 

TRAUMATIC  FEVER,  ERYSIPELAS,  AND  TETANUS 415 

By'  J.  Collins  Warren,  M.  D.,  Professor  of  Surgery,  Harvard  Medical 
School,  Boston. 

RABIES;  HYDROPHOBIA;  LYSSA 433 

By  Hermann  M.  Biggs,  M.  D.,  Professor  of  Therapeutics  and  Clinical  Medi- 
cine, formerly  Professor  of  Pathology,  Berevue  Hospital  Medical  College  ; 
Visiting  Physician  Bellevue  Hospital,  New  York. 

GUNSHOT  WOUNDS 445 

By-  Phineas  S.  Conner,  M.  D.,  Professor  of  Surgery  and  of  Clinical  Surgery, 
Medical  College  of  Ohio,  Cincinnati,  and  also  in  Dartmouth  Medical  College, 
Hanover,  N.  H. 

7 


8  CONTENTS. 

PAGE 

FRACTURES  AND  DISLOCATIONS 515 

Ev  Frederic  S.  Dennis,  M.  D.,  Professor  of  the  Principles  and  Practice  of 
Surgery,  Bellevue  Hospital  Jleilii'iil  College ;  Surgeon  to  the  liellevue  and 
St.  Vincent  Hospitals,  New  York. 

ANvESTHESIA 645 

By  Horatio  C.  Wood,  M.  D.,  LL.D.,  Professor  of  Materia  Medica,  Pliarniacy, 
and  General  Therapeutics,  I'Miversity  of  I'ennsylvania,  PliihuU-liihia. 

THE  TECHNIQUE  OF  ANTISEPTIC  AND  ASEPTIC  SURGERY 077 

By  Arpad  G.  Gerster,  M.  D.,  Professor  of  Surgery  in  the  New  York 
Polyclinic ;  Surgeon  to  the  German  and  Mt.  Sinai  Hasjiitals,  New  York. 

OPERATIVE  SURGERY 729 

By  Stephen  Smith,  M.  D.,  Emeritus  Professor  of  Clinical  Surgery,  I^niver.sity 
of  the  City  of  New  York  ;  Visiting  Surgeon  to  St.  Vincent,  and  Consulting 
Surgeon  to  Bellevue  Hospital,  New  York. 


THE  HISTORY  AND  LITERATURE  OF 
SURGERY. 

By  JOHN  S.  BILLINGS,  M.  D. 


In  this  sketdi  of  the  development  of  Surgery  during  the  last  three 
thousand  years  a  brief  account  is  given,  mainly  in  chronological  order, 
of  the  chief  discoverers,  improvers,  and  inventors  in  the  art,  and  also  of 
the  principal  teachers  of  it.  The  original  in\-entor  may  or  may  not  have 
been  a  lecturer  or  author,  and  the  date  of  the  first  improvement  in  a 
method  of  treatment  or  in  the  performance  of  a  new  operation  was  often 
long  prior  to  that  general  knowledge  of  such  improvement  which  is 
necessary  to  constitute  true  development.  Some  account  is  also  given 
of  the  trade,  guild,  or  craft  associations  or  corporations  of  surgeons,  and 
of  their  relations  to  education  and  to  legislation.  A  few  illustrations  of 
the  state  of  the  art  at  diflFerent  periods,  in  the  shape  of  the  recommenda- 
tions of  different  writers  with  regard  to  methods  of  treatment  of  certain 
injuries  or  diseases,  are  presented ;  but  no  attempt  is  made  to  trace  the 
history  of  the  growth  of  knowledge  with  regard  to  each  particular  form 
of  disease  or  oj:)eration,  this  being  left  to  the  writers  of  monographs  on 
these  particular  subjects. 

It  requires  leisure,  patience,  and  access  to  a  large  library  to  make 
historical  studies  really  interesting,  and  the  most  I  can  hope  to  accom- 
plish in  this  paper  is  to  furnish  to  the  physician  who  has  little  time, 
taste,  or  opportunity  for  consulting  the  original  documents  the  means  of 
ascertaining  the  periods  and  places  in  which  the  leading  surgeons  of  the 
world  have  done  their  work.  The  jirinted  literature  of  surgery  is  vast 
in  quantity,  and  the  great  majority  of  it  is  obsolete  and  practically  use- 
less :  even  for  statistical  ])urposes  the  records  of  operations  performed 
prior  to  1870  have  now  lost  much  of  the  value  which  they  possessed 
at  that  date ;  yet  in  many  respects  the  old  surgical  monographs,  col- 
lections of  cases,  and  systems  are  the  most  definite  and  interesting  of  all 
ancient  medical  literature. 

To  really  enjoy  the  history  of  surgery  it  is  necessary  to  consult  the 
original  documents — to  get  the  flavor  of  the  quaint  phraseology  of  the 
older  writers.  No  discourse  about  the  surgical  kno\\ledge  of  Hippoc- 
rates, however  eloquent"  and  eulogistic  it  may  be,  can  give  such  an  idea 
of  his  teachings  as  is  to  be  obtained  from  a  perusal  of  his  writings. 

It  is  not  to  be  expected  that  a  man  who  is  familiar  with  the  resources 
of  the  surgery  of  the  present  day  will  he  al)le  to  discover  in  the  ancient 
records  anything  of  much  practical  utility  in  his  daily  work  which  will 
be  new  to  him  ;  nevertheless,  if  he  desires  to  compare  his  experience  in 
a  particular  case  or  class  of  cases  with  tliat  of  his  predecessors — to  obtain, 

Vol,.  I.— 2  17 


18  THE  HISTORY  AM)   UTKnATrUK  OF  SUltOKRY. 

as  it  were,  a  sort  of  "parallax  in  time"  of  the  views  wliieli  liave  been 
held  on  tlie  subject  whieia  occupies  him — he  will  often  not  be  able  to  do 
this  from  the  (current  text-books.  It  will  be  neeessarv  that  he  should 
go  back  to  the  old  masters,  road,  comi)are,  and  think  ;  and  whenever  he 
does  this  it  is  safe  to  say  that  his  eonclusions  will  be  broader,  wiser, 
estal)lished  on  a  firmer  foundation,  and  more  interesting  to  those  to 
whom  he  imparts  them,  than  they  ^\■ill  be  if  derived  solely  from  his  own 
experience. 

In  the  history  of  the  development  in  civilization  of  nations  and 
peoples,  surgery  almost  necessarily  precedes  internal  medicine  with  regard 
to  accurate  observation  of  lesions  of  the  human  body  and  of  their  results. 
Speculations  about  humors  and  fluxes,  Idack  bile  and  medical  constitu- 
tions, vital  spirits  and  the  doctrine  of  signatures,  did  not  much  occupy 
the  minds  of  the  men  of  old  in  their  attempts  to  note  and  describe  the 
signs  of  different  forms  of  fractures  and  dislocations,  the  danger  of 
wovmds  in  diti'erent  localities,  the  different  varieties  of  tumors,  or  the 
treatment  of  a  calculus  in  the  bladder  or  of  a  hernia.  Of  the  many 
remedies  in  the  form  of  drugs,  sahes,  embrocations,  and  jjlasters  M'hich 
are  described  at  length  in  the  ancient  medical  books  which  have  come 
down  to  us,  hardly  more  than  twenty  are  now  in  ordinary  use ;  the 
ancient  physiology  and  pathology  are,  for  the  most  part,  now  considered 
as  being  merely  curious  illustrations  of  human  error;  and  it  is  only  a 
portion  of  the  anatomy  and  siu'gery  of  the  ancients  that  remains  as  an 
essential  part  of  the  foundation  of  the  art  cif  medicine  as  it  exists  to-day. 

The  history  of  surgery  is  inextricably  mingled  with  that  of  medicine, 
and  the  best  literature  on  the  subject  is  to  be  found  in  some  of  the  larger 
formal  treatises  on  the  history  of  medicine.  It  has,  however,  been  treated 
of  as  a  special  branch  of  the  art  in  a  goodly  number  of  Ijooks  and  essays, 
the  titles  of  a  portion  of  which  fill  se\'en  pages  of  volume  xiii.  of  the 
Index  Catalogue  of  the  Librarv  of  the  Surgeon-General's  Office  at  Wash- 
ington. 

The  earliest  records  in  our  possession  which  relate  to  surgical  opera- 
tions come  from  Egypt.  It  is  true  that  human  skulls  have  been  found 
belonging  to  the  Neolithic  or  Polished  Stone  Age,  which  have  had  por- 
tions removed — being  examples  of  the  so-called  jjrehistoric  trephining 
which  is  suj)posed  to  have  been  performed  in  cases  of  headache,  epilepsy, 
etc. — and  the  age  of  these  relics  is  unknown  ;  but  it  is  not  at  all  probable 
that  it  extends  to  the  time  of  the  pyramid-builders  in  the  valley  of  the 
Nile,  when  circumcision  had  been  established  as  a  religious  rite  and  an 
official  system  of  medicine  was  in  process  of  construction. 

The  Papyrus  Ebers,  written  1552  b.  c. — that  is,  at  least  a  century 
bef(Sre  the  exodus  of  the  Israelites — is  a  comj)ilation  of  receipts  and 
directions  for  the  treatment  of  various  diseases,  many  of  which  formulae 
it  refers  to  as  being  then  ancient.  Among  these  is  a  short  section  on 
tumors  near  the  surface  of  the  body,  in  which  it  is  said  :  "  If  this  tumor 
goes  and  comes  under  your  finger,  trembling  even  when  your  hand  is 
still,  say,  '  it  is  a  fatty  tumor,'  and  ti'eat  it  with  the  knife,  after  which 
treat  it  as  an  open  wound."  From  the  Papyrus  Ebcrs  we  learn  that 
there  were  physicians  in  Egypt  who  were  not  priests,  and  the  same  may 
be  iiiferred  from  the  statement  in  Genesis  (eh.  1.  2)  that  "  Joseph  com- 
manded his  servants  the  physicians  to  embalm  his  father,  and  the  phy- 


THE  HISTORY  AM)  LITERATURE  OF  SURGERY.  19 

sicians  embalmed  Israel."  The  word  in  this  text  wliieh  is  translated 
"phvsieians"  is  rephaiin,  and  it  is  sometimes  translated  as  "dressers  of 
wounds  " — /.  c.  surueons.  The  embalmers  probably  had  a  little  more 
anatomical  knowledge  than  the  physicians  of  the  time  ;  but  the  Egyjit- 
ians  had  a  treatise  on  anatomy  which,  according  to  Manetho,  was  attrib- 
uted to  Ath(itliis,  the  son  of  Menes,  who  reigned  5241  B.  c. 

The  few  allusions  to  medicine  scattered  through  the  books  of  the 
Old  Testament  indicate  that  the  general  belief  was  in  accord  with  that 
usually  found  prevailing  among  savage  tribes — viz.  that  most  diseases 
are  punishments  intlicted  by  divine  power,  and  to  be  removed  by  sacri- 
fices and  special  ceremonies ;  whence  it  follows  that  the  priests  were  the 
chief  medicine-men.  That  there  were  other  physicians  is  probable  from 
the  grimly  sarcastic  account  of  King  Asa,  who  "  in  his  disease  sought 
not  to  the  Lord,  but  to  the  physicians.  And  Asa  slept  with  his  fathers  ;" 
and  also,  perhaps,  from  Exodus  xxi.  19  :  "And  if  men  strive  together, 
and  one  smite  another  with  a  stone,  or  with  his  fist,  and  he  die  not, 
....  then  shall  he  that  smote  him  pay  for  the  loss  of  his  time,  and 
shall  cause  him  to  be  thoroughly  healed  ; "  or,  as  the  Sef)tuagint  has  it, 
"  and  shall  pay  the  physician's  fees." 

The  medicine  of  the  Bible  has  been  the  subject  of  several  learned 
essays,  but  it  does  not  appear  that  medicine  was  regularly  studied  among 
the  Jews  as  a  separate  profession  until  the  rise  of  the  Alexandrian 
School,  nor  does  either  the  science  or  the  art  of  medicine  owe  anything 
to  this  nation  until  after  this  period.  The  often-quoted  chapter  xxxviii. 
of  Ecclesiasticus  about  the  physician  is  of  late  date,  and  was  probably 
written  under  Greek  influence. 

Some  specimens  of  Jewish  surgery  prior  to  200  A.  d.  are  to  be  found 
in  the  Talmud.  The  ralibis  were  acquainted  with  sutures  for  wounds, 
with  the  method  of  freshening  the  edges  of  an  old  wound  to  obtain 
reunion,  with  the  employment  of  the  uterine  sound  to  learn  whether  the 
blood  came  from  the  uterus  or  vagina,  the  operation  for  imperforate  anus, 
and  also  with  an;esthctic  substances  with  which  they  used  to  diminish  the 
jwin  of  a  surgical  operation  or  capital  jtunishment.'  Thev  understood 
the  application  to  the  body  of  artificial  jjarts,  as  for  supplying  the  loss 
of  substance  of  the  trachea  and  replacing  the  loss  of  substance  of  the 
cranial  bone ;  they  knew  artificial  teeth,  wooden  legs,  as  also  various 
forms  of  apparatus  for  the  unfortunates  who  were  deprived  of  the  use 
of  their  lo«er  exti'emities. 

The  first  allusions  to  surgical  subjects  in  Greek  literature  are  found 
in  the  poems  of  Homer,  which  may  be  accepted  as  dating  from  about 
1000  B.  c,  whatever  may  be  thought  as  to  the  reality  of  the  siege  of 
Troy  or  the  identity  of  Homer  himself.  In  these  poems  mention  is 
made  of  ^Escnlapius,  not  as  a  god,  but  as  a  well-known  and  distinguished 
physician,  and  of  his  sons  INIaciiaon  and  Podalirius  as  surgeons  and  war- 
riors. The  works  of  Homer  have  been  carefully  examined  and  analyzed 
by  ^lalgaigne  and  Darcmberg  with  reference  to  medical  and  surgical 
matters,  and  their  conclusions  may  be  briefly  stated  as  follows:^ 

'  Rabbinowicz :  Ixi  Medecine  {hi  Thdhnu/l,  etc.,  Paris,  1880,  p.  xliii. 

^  "  Essai  sur  I'Histoire  et  rOrganisation  de  la  Chirurgie  et  de  la  M^decme  grecqiies 
avant  Hipjiocrate,''  par  M.  Malgaigiie,  Jour,  de  Med.,  iv.  303,  Paris,  1846 ;  La  Medecine 
dans  HomSre,  par  Ch.  Daremberg,  8°,  Paris,  1865. 


20  THE  HISTORY  AND  LITKRATVRE  OF  SUIiGERY. 

Among  tlie  Greeks  were  certain  surgeons  whose  knowledge  and  skill 
were  highly  esteemed ;  many  of  the  warriors  knew  how  to  dress  and 
bandage  wounds,  and  some  of  the  Grecian  women  had  the  same  skill, 
corresponding  to  that  possessed  by  the  wives  of  tlie  noi)ility  in  Western 
Europe  in  feudal  times.  The  dressings  aj)plied  to  the  wounds  a|)pcar  to 
have  been  for  the  most  part  simple  emollients :  the  effused  blood  was 
pressed  out,  the  surface  was  washed  with  warm  water,  certain  crushed 
roots  or  bruised  leaves  were  applied  to  check  hemorrhage.  Over  forty 
Mounds  in  different  parts  of  the  body  are  described  with  more  or  less 
detail,  and  in  such  a  way  as  to  indicate  that  Homer  gav(>  the  residts  of 
actual  observation  and  experience ;  and  in  the  course  of  these  descriptions 
a  nomenclature  is  used  which,  anatomically,  is  much  the  same  as  that 
employed  by  Hippocrates.  The  different  effects  of  Avounds  in  different 
parts  of  the  body  are  referred  to,  and  a  curious  illustration  of  this  occurs 
in  the  description  of  the  injury  of  one  of  the  horses  of  Nestor  by  an 
arrow  from  the  bow  of  Paris  (viii.  81-86).  The  wound  was  on  the  top 
of  the  head,  penetrating  to  the  brain,  and  it  is  said  that  the  injured  animal 
was  convulsed  and  turned  round  and  round  the  pole.  This,  as  INIalgaigne 
points  out,  corresponds  to  the  modern  discovery  that  such  movements  of 
rotation  are  produced  by  an  injury  of  the  cerebellum. 

The  anatomical  terms  used  by  Homer  relate  mainly  to  the  exterior 
of  the  body,  and  do  not  imply  any  greater  knowledge  of  internal  struc- 
ture tlian  is  possessed  by  every  butcher  ;  but  his  allusions  to  the  fatality 
of  certain  wounds  embody  tlie  results  of  considerable  experience.  There 
is  nothing  of  surgical  interest  in  Greek  literature  between  the  time  of 
Homer  and  that  of  the  Hippocratic  Writings,  unless  it  be  the  passage  in 
Aristophanes  in  which  the  slave  of  Lamachus  calls  for  hot-water  com- 
presses, etc.  with  which  to  dress  the  sprained  ankle  of  his  master. 

In  the  fifth  and  sixth  centuries  B.  c.  there  were  in  Greece  and  Great 
Greece  between  fifty  and  sixty  temples  of  ^sculapius,  all  of  which  were 
probably  resorted  to  by  the  sick,  but  those  which  became  specially  cele- 
brated were  those  of  Rhodes,  Cyrene,  Cnidos,  and  Cos.  Those  at  Ciiidos 
and  Cos  gradually  became  the  most  famous,  and  their  so-called  "  schools  " 
occupy  a  prominent  jjlace  in  the  history  of  medicine. 

By  the  term  "medical  schools"  as  applied  to  Cos  and  Cnidos  it  is  not 
meant  that  these  were  places  for  the  jiublic  teaching  of  medicine,  but 
rather  that  they  Avere  j)laces  where  certain  medical  families  had  settled, 
and  in  each  of  which  certain  peculiar  theories  and  methods  of  treatment 
prevailed,  the  phrase  "  school  "  being  used  nuich  as  we  Mould  noM'  speak 
of  the  "French"  or  the  "Munich"  school  in  painting. 

In  the  vicinity  of  these  temj)les  there  seem  to  have  collected  physi- 
cians M'ho  Mere  not  priests,  and  M'ho  belonged  to  an  association  or  bro- 
therhood, the  members  of  which  either  claimed  to  be  descendants  of 
^sculapius  or  M'ere  admitted  to  the  guild  by  ad()ption  M'ith  sjjecial  cere- 
monies. These  were  knoM'n  collectively  as  the  "^Esclepiadje,"  and  much 
confusion  has  arisen  from  the  erroneous  ajjplication  of  this  term  in  later 
times  to  those  M-ho  ministered  in  the  temple.  There  is  no  doubt  that  the 
]iricsts  of  the  temj^le  gave  medical  ad\ice,  but,  if  Me  are  to  judge  from 
the  specimens  preserved  to  us  in  the  forms  of  inscriptions  and  memorial 
tablets,  it  M'as  not  the  sort  of  advice  of  Mhich  any  use  is  made  in  the 
medical  treatises  of  the  Hippocratic  school. 


THE  HISTORY  AND  LITKRATVEE  OF  SURGERY.  21 

It  is  probable  that  the  real  or  lay  physicians  kept  records  which  were 
handed  down  from  father  to  son,  and  were  jireserved  as  a  valnable  family 
heritage.  That  medicine  was  thus  hereditary  we  know  from  the  ilip- 
pocratic  oath,  and  from  the  genealogies  which  are  given  of  many  of  the 
celebrated  physicians  of  Greece.  According  to  Bertrand,  this  custom  has 
come  down  to  the  present  time.  On  one  of  the  slopes  of  Pindus  there 
are  still  five  or  six  villages  the  inhabitants  of  which  are  supposed  to  be 
born  phvsicians  and  surgeons,  each  family  having  its  own  specialty  and 
its  inherited  tradition.  If  a  son  is  wanting,  the  child  of  a  stranger  is 
adopted. 

There  is  no  evidence  that  those  who  visited  the  temples  seeking  mirac- 
ulous cures  were  examined  or  treated  by  lay  physicians,  but  there  were 
certain  attendants  called  zacoroi  who  received  the  patients  and  assigned 
them  to  ])laces  beneath  the  porticos;  and  from  tlie  information  collected 
by  them  it  is  possible  that  the  priest  who  impersonated  the  god,  appearing 
in  the  night-watches,  may  sometimes  have  formulated  his  prophecies  and 
instructions. 

The  doctrines  of  the  schools  of  Cos  and  Cnidos  were  committed  to 
writing,  the  first  work  of  the  kind  coming  from  the  school  of  Cnidos, 
being  what  is  known  as  the  "  Cnidian  Sentences."  Of  this  treatise  there 
were  at  least  two  editions,  and  it  was  in  existence  in  the  time  of  Galen. 
A  portion  of  it  has  been  preserved  to  us  in  what  are  known  as  the  Second 
and  Third  Books  of  Diseases,  and  in  the  Treatises  on  Internal  Affections 
contained  in  the  Hippocratic  collections. 

In  this  portion  four  diseases  of  the  kidneys  are  described.  In  the  first 
there  is  acute  ])ain  in  the  loins,  groin,  and  the  testicle  of  the  affected  side 
(renal  colic) ;  there  is  frequent  urination,  with  gradual  suppression  of  urine 
and  passage  of  .sand,  causing  pain  in  the  urethra.  A2>ply  warmth  and 
purge  with  scammony.  If  the  pain  is  great,  use  large  euemata  of  warm 
■water ;  if  a  tumor  forms,  make  an  incision  over  the  kidney  and  evacuate 
the  pus.  Such  incision  gives  a  chance  of  recovery ;  without  it  death 
will  follow. 

In  the  second  form  of  disease  of  the  kidney  there  are  violent  pains, 
as  in  the  preceding  form.  The  patient  passes  blood  with  his  urine  at  the 
commencement  of  the  disease,  which  is  followed,  after  a  time,  by  pus. 
If  he  preserves  a  strict  rest,  he  will  be  cured  rapidly,  but  if  he  makes 
effort,  the  pains  will  become  sharper.  When  the  kidney  is  filled  with 
pus  it  swells  out  near  the  spine  ;  in  this  case  make,  over  the  swelling,  an 
incision,  generally  deep,  into  the  kidney.  If  you  succeed  in  the  incision, 
you  will  cure  the  patient  at  once ;  if  you  fail,  it  is  to  be  feared  that  the 
wound  will  not  close,  and  the  borders  of  the  wound  will  contract  and  the 
cavity  of  the  kidney  will  be  filled  with  pus ;  if  this  passes  inward  and  is 
evacuated  by  the  rectum,  there  is  a  chance  of  health  ;  but  if  it  affects  the 
other  kiduev,  death  is  to  be  feared.  Evacuants  are  to  be  used,  and  the 
same  regimen  as  for  the  preceding  case.  Very  often  this  disease  termi- 
nates by  a  renal  phthisis. 

The  school  of  Cos  followed  with  its  collection  of  maxims,  the  "  Prse- 
notiones  CoaciB."  Its  doctrines  will  be  best  considered  in  the  work  of 
its  most  illustrious  disciple,  Ilipiiocrates,  who  was  born  at  Cos  about  460 
B.  c.  His  father,  Heraclidcs,  and  his  grandfather  were  physicians,  and 
he  received  his  earlv  education  at  tlie  school  of  Cos,  after  which  he  went 


22  THE  HISTORY  AND  LITERATURE  OF  SURGERY. 

to  Athens  and  continued  lii.s  studios,  re(rivin<:,  the  liest  echication  which 
the  Golden  Age  of  Greek  civilization  could  furnish. 

The  collection  known  as  tiie  "Hippocratic  Writiuirs"  dates  from  a 
period  about  the  time  of  Aristotle.  Only  a  jxd'tion  of  these  writinj^s  are 
the  works  of  Hippocrates  himself;  several  are  probablv  of  more  ancient 
date — two  at  least  appear  to  belong  to  the  Cnidian  School,  and  some  are 
by  his  disciples.  On  the  otlier  iiand,  some  of  those  which  once  belonged 
to  this  collection  have  been  lost. 

The  books  in  the  Hijjpocratic  collection  which  treat  more  especially 
of  surgical  affections  and  o]x'rations,  and  which  are  accc2)ted  bv  most 
commentators  as  having  been  written  eitiier  by  Hippocrates  himself  or 
by  one  of  his  immediate  pupils,  are  those  on  injuries  of  the  head,  on 
fraetui'es,  on  the  articulations  (/.  e.  on  dislocations),  Mochlicns  (on  the 
bones  and  their  injuries  and  displacements,  and  on  apparatus),  on  M'ounds 
and  ulcers,  on  fistulfe,  on  hemorrhoids,  and  on  the  latrium  or  the  Physi- 
cian's Establishment,  or  the  Surgery. 

The  book  on  injuries  of  the  head  liegins  witli  a  description  of  the 
sutures  of  the  cranium  and  of  the  bones  ol"  the  skull,  in  which  it  is  stated 
that  the  number  and  position  of  the  sutures  varies  with  the  form  of  the 
head  ;  that  the  coronal  suture  is  wanting  when  there  is  no  anterior  pro- 
tuberance of  the  skull,  and  the  lambdoid  suture  is  wanting  when  there 
is  no  posterior  protuljerance.  As  this  does  not  agree  with  the  oI)serva- 
tions  of  modern  anatomists,  the  commentators  have  much  troul^le  to 
explain  it,  since  they  are  unwilling  to  atlmit  that  Hippocrates  made  a 
mistake  in  observation,  or  even  that  he  generalized  from  insufticicnt 
data ;  which  last  is  the  most  probable  explanation. 

He  divides  injuries  of  the  bones  of  the  skull  into  five  classes — viz. 
simple  fissures,  contusions  without  fracture  or  depression,  fractures  with 
depression,  indentations  of  the  outer  tabic,  and  fractures  at  a  distance 
from  the  place  of  injury,  or  fracture  l)y  coutrc-coup.  AVith  regard  to 
this  last  he  says :  "  There  is  no  remedy,  for  vhen  this  mischief  takes 
place  there  is  no  means  of  ascertaining  by  any  examination  whether  or 
not  it  has  occurred,  or  on  what  part  of  the  head."  He  then  goes  on  to 
say  :  "  Of  these  modes  of  fracture  the  following  require  trepanning  :  the 
contusion,  whether  the  bone  be  laid  bare  or  not ;  and  tiie  fissure,  \\hether 

apparent  or  not ^V  bone  depressed  from  its  natural  jiosition 

rarely  requires  trepanning,  and  those  which  are  most  jjressed  and  broken 
require  trepanning  the  least." 

It  will  be  seen  that  this  is  quite  different  from  the  rules  of  modern 
practice. 

For  wounds  of  the  head  he  forbids  the  application  of  any  liquors  or 
cataplasms  or  tents,  unless  the  wound  is  on  the  forehead  or  the  part 
which  is  bare  of  hairs  or  about  the  eyebrow  and  eye.  The  wound  is  to 
be  extended  by  incisions  for  the  purpose  of  examining  tiie  bone  when- 
ever it  is  suspected  that  this  is  injured  ;  and  it  is  remarked  that  these 
incisions  may  be  practised  with  impunity  except  on  the  temjile  and  the 
parts  above  it,  where  there  is  a  vein  that  runs  across  the  temple,  in  which 
region  an  incision  is  not  to  be  made  ;  "  for  convulsions  seize  on  a  person 
who  has  been  thus  treated  ;  and  if  the  incision  be  on  the  left  temple,  the 
convulsions  seize  on  the  right  side ;  and  if  the  incision  be  on  the  right 
side,  tlie  convulsions  take  place  on  the  left  side." 


THE  HISTORY  AXD  LITERATURE  OF  SURGERY.  23 

Tho  books  on  fractures  and  on  the  articulations,  together  with  the 
book  called  "  Mochlicus,"  contain  sketches  of  the  anatomy  of  the  bones 
and  of  the  joints,  and  accoiuits  of  various  forms  of  dislocations  of  the 
diti'erent  joints,  with  detailed  instructions  as  to  reduction  and  as  to  the 
mode  of  bandaging  in  cases  of  fracture.  Special  attention  is  given  to  the 
subject  of  injuries  affecting  the  knee-,  the  elbow-,  and  the  ankle-joints. 

The  paragraph  on  disk)cations  of  the  knee  does  not  correspond  to  the 
experience  of  modern  surgeons.  It  is  as  follows  :  "  Luxations  and  sub- 
luxatitins  at  the  knee  are  much  milder  accidents  than  subluxations  and 
luxations  at  the  elbow ;  for  the  knee-joint,  in  proportion  to  its  size,  is 
more  compact  than  that  of  the  arm,  and  has  a  more  even  conformation, 
and  is  rounded,  while  the  joint  of  the  arm  is  large  and  has  many 
cavities 

"  Owing  to  their  configuration,  the  bones  of  the  knee  are  indeed  fre- 
quently dislocated,  but  they  are  easily  reduced,  for  no  great  inflanniiation 

follows   nor   any  constriction  of  the  joint They  are  displaced 

for  the  most  part  to  the  inside,  sometimes  to  the  outside,  and  occasion- 
ally into  the  ham.  The  reduction  in  all  these  cases  iS  not  difficult,  but 
in  the  dislocations  inward  and  outward  the  patient  should  be  placed  on 
a  low  seat,  and  the  thigh  should  be  elevated,  but  not  much.  Moderate 
extension  for  the  most  part  sufficeth,  extension  being  made  at  the  leg  and 
counter-extension  at  the  thigh. 

"  Dislocations  at  the  elbow  are  more  troublesome  than  those  at  the 
knee,  and,  owing  to  the  inflammation  which  comes  on  and  the  config- 
uration of  the  joint,  are  more  difficult  to  reduce  if  the  bones  are  not 
inuuediatcly  replaced.  For  the  bones  at  the  elbow  are  less  subject 
to  dislocation  than  those  of  the  knee,  but  are  more  difficult  to  reduce 
and  keep  in  their  position,  and  are  more  apt  to  become  inflamed  and 
ankylosed." 

Some  of  the  older  surgeons  concur  with  Hippocrates  in  speaking  of 
dislocations  of  the  knee  as  comparatively  fre(pient,  whereas  at  present 
they  are  very  rare.  Dr.  Adams  supposes  that  the  wrestlers  at  the  public 
games,  who  furnished  Hippocrates  with  a  Uu'ge  proportion  of  his  cases 
of  fractures  and  dislocations,  may  have  been  especially  liable  to  this 
accident.  Hippocrates  says  that  he  knows  of  but  one  way  in  which  the 
shoulder-joint  is  dislocated — namely,  that  into  the  armpit ;  but  he  does 
not  deny  that  the  head  of  the  humerus  might  be  dislocated  upward,  out^ 
ward,  or  forward.  The  methods  of  reduction  are  fairly  described,  and 
are  substantially  those  which  are  used  at  the  ])reseut  day. 

He  has  much  to  say  in  various  places  about  congenital  dislocations, 
some  of  which  may  be  reduced  to  their  natural  condition,  and  especially 
those  at  the  ankle-joint. 

In  cases  of  compound  dislocations  he  forbids  reduction,  as  a  general 
rule.  For  example,  in" speaking  of  dislocation  at  the  ankle-joint  com- 
plicated with  an  external  wound,  he  says  you  are  not  to  reduce  the  parts, 
but  let  any  other  physician  reduce  them  if  he  choose ;  "  for  this  you 
should  know  for  certain,  that  the  patient  will  die  if  the  parts  are  allowed 
to  remain  reduced,  and  that  he  will  not  survive  more  than  a  few  days, 
for  few  of  them  pass  the  seventh  day,  lieing  cut  off"  by  convulsions  ;  but 

sometimes  the  leg  and  foot  are  seized  witii  gangrene But  if  not 

reduced  nor  any  attempts  first  made  to  ri'(hice  them,  most  of  such  cases 


24  THE  HISTORY  AND  lATERATURE  OF  SURGERY. 

recover.  The  leg  and  foot  are  to  lie  arranged  as  the  patient  wishes,  only 
they  must  not  be  ])iit  in  a  dependent  jiosition  nor  moved  ahout." 

In  speaking  of  these  eomj^nnnd  dislocations  he  makes  no  allnsidii  to 
cutting  ofl'  the  protruding  end  of  the  bone,  but  in  another  section  he 
remarks  that  "  complete  resections  of  bones  at  the  joints,  whether  the 
foot,  the  hand,  the  leg,  the  ankle,  the  forearm,  the  wrist,  for  the  most 
part  are  not  attended  with  danger,  unless  one  be  cut  oif  at  once  by  de- 
li([uiiun   animi  or  if  eontiiuial   fevers  supervene  on   the  fourth   day." 

Hippocrates  knew  nothing  about  amputation  of  lindjs  as  an  o])eration 
through  living  parts  or  with  a  view  to  forming  a  stump  of  a  particular 
shape.  In  cases  of  gangrene  due  to  the  crushing  of  the  blood-vessels,  or 
following  fractures  when  the  bandages  have  been  applied  too  tightly,  he 
remarks  that  the  most  of  such  patients  recover,  even  when  a  portion  of 
the  thigh  conies  away  or  of  the  arm,  and  when  the  forearm  and  leg  drop 
oif  the  patients  rapidly  recover. 

The  sui'gical  part  of  the  Hippocratic  collection  is  much  more  in 
accordance  with  modern  views  than  the  medical  part ;  but  there  are 
certain  characteristics  of  all  the  books  generally  considered  to  have  been 
written  by  Hippocrates  himself  which  are  worthy  of  special  attention  in 
connection  with  the  high  repute  in  -which  they  ha\e  been  held  by  med- 
ical men  for  over  two  thousand  years.  In  the  first  place,  it  is  evident 
that  one  of  his  special  aims  was  to  be  entirely  honest  and  truthful  in  his 
statements.  He  reports  no  marvellous  cures,  no  sjiecimens  of  extraor- 
dinary success  in  diagnosis  where  others  had  failed;  fatal  cases  are  given 
as  well  as  recoveries,  and  there  are  no  hints  that  the  former  were  not  seen 
in  time  or  that  they  had  been  improperly  treated  by  others.  He  seems  to 
have  written  mainly  for  the  purpose  of  telling  what  he  himself  knew ; 
and  this  motive — i-ai-e  among  all  writers — is  especially  rare  among 
writers  on  medicine. 

A  second  characteristic  of  the  Hijipocratic  Writings  is  the  special 
attention  given  to  those  symptoms  which  indicate  the  effect  which  the 
disease  is  producing  upon  the  body  as  a  whole,  including  such  phenomena 
as  fever,  debility,  delirium,  restlessness,  and  so-called  critical  discharges 
of  various  kinds  ;  while  the  special  diagnostic  signs  of  particidar  forms 
of  disease  of  particular  organs  are  given  much  less  attention. 

The  aphorism  of  Hippocrates  concerning  the  efficiency  of  fire — 
namely,  "  that  diseases  which  are  not  cured  by  medicines  are  cured  by 
iron  ;  those  which  are  not  cured  by  iron  are  cured  by  fire ;  those  not 
cured  by  fire  are  incurable  " — has  been  the  cause  of  an  enormous  amount 
of  suifering  and  of  bad  surgery  to  nearly  the  present  centuiy. 

Surgery  of  India  and  China. 

In  the  literature  of  India  the  first  definite  hymns,  invocations,  and 
charms  connected  with  medicine  are  foiuid  in  the  fourth  (or  Atharva) 
Veda.  The  oldest  existing  medical  work  is  the  Charaka-samhita,  of 
which  the  Sanscrit  text  has  been  published  in  1877,  and  of  which  an 
English  translation  is  now  in  course  of  publication.  Somewhat  later, 
probably,  is  the  Susruta,  of  which  two  Sanscrit  editions  have  been  pub- 
lished ;  also  a  Latin  translation  by  Dr.  F.  Hessler,  published  at  Elrlangen 
in  1844.     English  translations  are  in  progress  of  publication,  and  a  sum- 


THE  HISTORY  AXD  LITERATURE  OF  SURGERY.  25 

marv  is  given  bv  Dr.  Wise  in  his  history  of  Indian  medicine.  Botli 
Charaka  and  Susruta  profess  to  be,  and  are  commonly  said  to  be,  commen- 
taries on  the  Aynr-Veda — /.  e.  the  Veda  of  Life — but,  in  tact,  there  is  no 
such  work  as  the  Ayur-Veda  distinct  from  and  preceding  Charaka  and 
Susi'uta. 

The  date  of  composition  of  these  works  is  unknown,  and  is  variously 
estimated  at  from  1000  B.  c.  to  700  A.  D.  Recent  authorities  consider  that 
the  later  date  is  the  more  probable  one,  and  that  the  work  took  its  jiresent 
form  under  the  influence  of  ideas  derived  from  the  Alexandrian  School 
and  the  early  Arab  writers.  It  was  certainly  known  in  tiie  ninth  century 
A.  D.  Nevertheless,  it  shows  little  trace  of  a  knowledge  Iw  the  author  of 
the  Hippocratic  Writings  or  of  the  discoveries  of  the  Alexandrian  anato- 
mists and  surgeons,  and  it  contains  a  number  of  things  peculiar  to  itself 
and  probably  derived  from  ancient  Indian  traditions. 

The  translation  of  Susruta  by  Anna  Moreshvar  Kunte,  of  which  the 
first  numbers  were  published  in  Bombay  in  1877,  begins  as  follows  : 

"Salutation  to  Brahma,  Prajapati,  the  twin  Asvins,  Iiulra,  Dhan- 

vantari,  Susruta,  and  others. 
"  Now,  hereafter,  we  .shall  narrate  the  chapter  named  the  descent  of 
knowledge  (of  medicine)  just  as  it  was  taught  to  Susruta  by  the  \enerable 
Dhanvantari.  Aupadhenava,  Vaitarana,  Aurabhra,  Paushkalavata,  Kara- 
virya,  Gopura,  Rakshita,  Susruta,  and  his  other  friends  in  earnest 
addressed  the  venerable  Dhanvantari,  the  respected  of  gods  (then 
known  by  the  name  of  Divodasa),  the  descendant  of  Kasiraja,  who  was 
leading  the  life  of  a  hermit,  surrounded  by  a  number  of  sages :  '  Sire  ! 
we  arc  moved  with  compassion,  seeing  human  beings,  though  protected 
(by  their  kings),  yet  quite  helpless,  being  afflicted  with  numerous  bodily, 
mental,  natural,  and  accidental  maladies.  We  wish  to  be  instructed  in 
the  Science  of  jNIedicine  for  the  sake  of  jiublic  good,  for  earning  our 
livelihood,  and  for  allaying  the  sufferings  of  mankind  desirous  of  health. 
Earthly  and  heavenly  bliss  depends  upon  it.  Hence,  Sire,  we  have  come 
to  you  to  become  your  pupils.' 

"  To  them  said  the  venerable  man  :  '  Ye  are  welcome.  All  of  you, 
my  lads,  shall  be  taught  and  made  to  meditate.  Ayur-Veda  is  an  Upanga 
of  the  Atharva-Veda.  The  Self-born,  after  creating  the  universe,  com- 
posed it  in  a  thousand  chapters,  containing  a  hundred  thousand  verses. 
But,  knowing  the  brevity  of  human  life  and  the  limitedness  of  human 
understanding,  he  reduced  it  to  eight  divisions.  These  are  :  1.  Shalyam, 
splinter  (extraction)  surgery  ;  2,  Shalakyam,  iiKpiiry  into  the  disease  of 
organs  situated  above  the  clax'icles  ;  ."3,  Kayachikitsa  treats  of  diseases 
affecting  the  whole  body  ;  4,  Bhutavida  treats  of  diseases  of  mind  jiro- 
duced  by  demoniacal  influences ;  5,  Koumarabhrityam,  care  and  treatment 
of  children  ;  6,  Agadatantram,  doctrine  of  antidotes  ;  7,  Rasayanatantra, 
doctrine  of  elixirs ;  8,  Vajikaranatantram,  rules  for  increasing  the  gen- 
erative jKiwers.  Which  of  tliese  do  you  wish  to  be  taught"?' — 'Sire,' 
said  they,  '  teacli  us  all,  but  begin  with  surgery  first.' — 'Be  it  so,'  said 
he. — Tiiey  again  requested  liim,  saying,  '  Susruta,  after  consulting  us  all, 
shall  ask  you  for  explanations  (in  matters  of  doubt),  and  whilst  he  is 
made  to  understand  we  shall  also  try  to  do  the  same.' — '  Well,  then,  my 
pupil,  Susruta,'  said  he,  '  the  Science  of  Medicine  has  for  its  object  the 
emancipation  from  disease  of  tliose  who  are  afflicted  by  it,  and  the  jires- 


26  THE  HISTORY  AXD  LITERATUnE   OF  SI'ROERY. 

ei'vation  of  the  health  of  tliose  wlio  possess  it.  Ayur-Veda  is  so  called 
hecaiise  Ijy  it  health  is  gained  or  it  hrin<i;s  health.  The  best  portion  of 
it  I  explain  to  you  :  try  to  follow  me  and  judge  by  the  four  criteria  of 
judgment — namely,  inference,  comparison,  testimony,  and  perception. 
It  is  the  best,  because  the  first  inflicted  wound  was  healed  (by  its  know- 
ledge), and  the  head  of  Yajna  was  united  to  his  trunk.  It  is  said  that 
when  Rudra  cut  of  the  head  of  Yajna  the  gods  went  to  the  twin  Asvins 
and  said  to  them,  "  Yon  two  are  of  a  higher  rank  amongst  us.  We 
entreat  you  to  join  together  Yajna's  head  and  trunk."  They  complied 
witii  the  request.  For  their  sake  the  gods  ]u-o])itiated  Indra  and  allowed 
them  a  share  in  his  sacrifice.  They  forthwith  joined  the  head  and  trunk 
together.  Of  all  the  eight  parts  of  which  the  Ayur-Veda  is  composed, 
this  is  the  best,  from  the  speediness  of  its  operations,  from  its  including 
the  use  of  appliances,  surgical  instruments,  caustics,  cauteries,  and  from 
its  being  ccjnuuon  to  tlie  otlier  parts  (of  the  science).  Thus  it  is  eternal, 
merit-giving,  divine,  leading  to  renown,  longevity,  and  prosperity. 

" '  The  great  god  Brahma  announced  (the  knowledge  of  medicine) 
first ;  Prajapati  learnt  it  from  him  ;  the  twin  Asvins  got  it  from  Prajajiati ; 
from  them  Indra ;  and  from  Indra  have  I  learnt  it.  I  am  going  to 
impart  it  to  anyI)ody  who  seeks  it  for  tiie  sake  of  public  good. 

" '  On  the  preliminary  preparations  (rules  to  be  observed  before,  dur- 
ing, and  after  the  completion)  of  surgical  operations  : 

" '  Every  action  (to  be  successi'ul)  involves  three  stages — viz.  1, 
the  prejjaratory  stage ;  2,  the  predominant  stage ;  3,  the  succeeding 
stage.  We  shall  point  out  that  the  treatment  of  diseases  has  these 
three  stages. 

" '  In  this  science  the  use  of  edged  instruments  is  considered  to 
be  predominant.  Hence  we  shall  begin  our  description  with  it  and 
its  accessories.  Edged  instruments  are  used  for  eight  purposes — viz.  1, 
amjDutating  ;  2,  opening ;  3,  scarifying  ;  4,  puncturing  ;  o,  exploring ;  6, 
drawing ;  7,  evacuating ;  and  8,  sewing.  A  surgeon  contemplating  to 
operate  in  any  of  tiie  above  ways  should  first  have  ready  the  following : 
blunt  instruments  (forceps,  etc.),  sharp  instruments,  potential  cauteries, 
virtual  cauteries,  catheters,  horns,  leeches,  a  dry  gourd,  a  cauterizing 
needle,  stufiing  materials,  strings,  board,  bandage,  honey,  ghee,  fat,  milk, 
oil,  soothing  decoctions,  injections,  lotions,  fan,  cold  and  warm  water,  a 
frying-pan,  aljle,  steady,  and  attached  servants. 

" '  Then  on  a  good  day,  having  a  good  lunar  influence  and  the 
auspicious  influence  of  stars,  after  invoking  blessings  from  the  Brah- 
mans  and  medical  men,  and  propitiating  the  sacred  fire  with  honey,  rice, 
and  water,  let  the  patient  be  seated,  who  has  taken  very  little  food, 
oifered  sacrifices,  and  made  ablutions,  with  his  face  toM'ard  the  east. 
The  surgeon  should  stand  with  his  face  toward  him,  and  plunge  his 
instrument  after  the  ]iroper  incision  imtil  matter  comes  out,  and  with- 
draw it,  avoiding  vital  j^arts,  vessels,  muscles,  articulations,  l)ones,  and 
arteries.  In  the  case  of  a  large  collection  of  matter  the  incision  may 
be  of  the  breadtii  of  two  or  three  fingers  even. 

" '  Incisions  ar'e  either  long,  wide,  even,  or  uneven.  An  incision, 
whether  long,  broad,  clean,  or  dependent,  is  always  to  be  extolled  when 
it  suits  (the  purpose  and)  the  occasion.  Boldness,  rapidity  of  action, 
sharp  instruments,  operation  without  trembling,  fear,  or  doubt,  are  always 


THE  HISTORY  AND  LITEEATUBE  OF  SURGERY.  'll 

praiseworthy  of  the  sur^-eon  operating Tlie  operations  for  moles, 

ascites,  piles,  calculus,  fistula,  and  mouth  diseases  are  to  be  performed  on 

an  empty  stomacli Tlie  instruments  sliould  be  so  made  that  they 

siiould  be  of  a  good  finish,  strong,  clean  in  api)earance,  with  good  handles, 
wiiether  they  be  sharp  or  blunt. 

"  'Among  these  the  Svastika  instruments  ought  to  be  about  nine  inches 
long ;  their  mouths  should  be  respectively  like  those  of  a  lion,  tiger, 
wolf,  hyena,  bear,  elephant,  cat,  hare,  antelope,  crow,  heron,  dog,  jay, 
vulture,  falcon,  owl,  kite,  cock,  crouch,  the  bee,  rat,  mouse,  or  bullock, 
each  half  being  united  to  the  other  by  a  nail  of  the  form  of  a  lentil- 
seed,  being  bent  inward  at  the  handles  like  the  elephant-driver's  hook. 
These  forceps  are  recommended  for  the  extraction  of  splinters  lodged  in 
bones. 

" '  The  tubular  instruments  are  of  a  variety  of  kinds,  having  various 
uses,  open  at  one  end  or  both  or  having  several  foraminje.  They  are 
used  for  removing  olistructions  from  the  great  canals  of  the  bodv,  or  for 
examination  of  diseases,  or  as  suction-tubes,  or  for  the  easy  application 
of  remedies.  Their  lengths  are  always  determined  by  the  apertui-e 
of  the  canal  whence  the  obstruction  is  to  be  removed  or  by  the  use  to 
which  they  are  to  be  ajiplied. 

"  '  The  diffei-ent  tubular  instruments  which  are  used  in  fistula,  hemor- 
rhoids, polypi,  sores,  urethral  injections,  enemas,  retention  of  urine, 
ascites,  inhalation  for  cough  and  dyspncea,  and  obstruction  of  bowels, 
together  with  the  bottle-gourd  and  the  horns,  shall  be  described  hereafter 
in  their  proper  places. 

" '  The  probe-like  instruments  are  of  various  kinds  and  serve  a  variety 
of  purposes.  Their  magnitudes  differ  according  to  the  uses  they  are 
applied  to.  Among  them  the  earthworm-like  probe,  the  arrow  probe, 
the  serpent-hood  probe,  and  the  hook  j^robe  are  each  of  them  two  in 
numljer.  They  have  l)een  recommended  for  sounding,  separating,  loosen- 
ing, and  extracting  (foreign  bodies).  Probes  having  lentil-seedlike  ends 
are  two.  They  are  slightly  curved  inward  at  their  extremities,  and  are 
used  for  the  extraction  of  foreign  bodies  from  the  large  canals.  There 
are  six  prolies  wliit'h  are  capped  with  cotton  wool,  and  are  used  for 
cleaning  and  wiping  purposes.  Tliere  are  three  which  are  ladle-like  and 
mortar-like,  and  are  used  for  application  of  caustics.  Three  others  there 
are  which  have  their  ends  like  a  jambul-seed.  Three  others,  again,  resem- 
bling the  elephant  hook.  These  six  are  used  for  cauterizing  purposes. 
There  is  a  nasal-polypus  probe  which  resembles  the  kolasthi.  There  is 
the  inunction  probe,  whii-h  at  its  both  extremities  has  a  knob  like  the 
pea-seed,  resembling  an  ojion  liud.  There  is  the  urinary  catheter,  which 
resembles  the  stalk  of  malati-  [Jasnuninin  gh(n<iiJior((~\  flower,  and  its 
length  varies  according  to  purpose 

"  '  The  lion-mouth  forceps  is  for  foreign  bodies  that  can  be  seen,  while 
for  covered  ones  there  is  the  heron  forceps  and  others  of  its  kind.  These 
should  be  used  gently,  the  foreign  body  being  removed  in  accordance 
with  surgical  precepts. 

"  '  The  heron  forceps  is  the  best  of  all  forceps,  since  its  use  never  leads 
to  accidents.  It  enters  easily  and  is  very  easily  drawn  back.  It  lays  a 
firm  hold  on  splinters  and  removes  them  easilv.' " 

Xo  allusions  are  made  to  the  use  of  the  ligature,  but  amputations  of 


28  THE  HISTORY  AND   WrERATURE  OF  SURGERY. 

tlic  limbs  were  performed,  the  lieiiiurrluige  being  elieeiietl  by  tiie  cautery, 
by  boiling  oil,  and  by  pressure. 

The  operation  of  lithotomy  is  described,  being  that  of  "  cutting  on 
the  gripe,"  the  incision  Ix'ing  made  on  either  the  left  or  the  right  side  of 
the  perineum,  the  breadth  of  a  liarley-coru  from  the  central  line  and  an 
inch  from  the  anus. 

The  sui)ra})ubic  o])cration  was  also  known,  rhinoplasty  is  described, 
and  herniotomy  is  referred  to.  Manual  skill  was  to  be  acquired  by  the 
student  by  making  jiunctures  and  incisions  on  gourds  and  other  fruits  or 
on  dead  animals. 

Fractures  and  dislocations  are  described  with  considerable  detail  of 
classification,  and  the  bamboo  sjilints  recommended  are  still  in  use.  The 
most  original  thing  in  the  work  is  the  part  which  relates  to  plastic  sur- 
gery, and  especially  to  rhinoplasty. 

Of  the  history  of  surgery  in  China  almost  nothing  is  knoM'n.  Hwa 
T'o,  who  is  supposed  to  have  lived  in  the  third  century  a.  d.,  is  ordinarily 
considered  to  have  been  the  father  of  surgery  in  China.  He  is  said  to 
have  performed  abdominal  section  for  the  local  treatment  of  diseased 
viscera ;  to  have  laid  bare  the  scapula  of  a  certain  great  military  hero 
and  scraped  from  it  certain  poison,  possibly  carious  bone ;  also  to  have 
relieved  by  acupuncture  an  affection  of  -the  brain  of  another  famous 
general  of  his  time.  It  does  not  appear  that  tiiis  was  entirely  successful, 
however,  for  he  subsequently  proposed  trejiliining  for  the  surgical  cure 
of  this  disease,  on  which  the  indignant  general  is  stated  to  have  declared 
him  a  traitor  who  was  plotting  his  death,  and  to  have  had  him  beheaded. 

Ch'iin  Kwei  in  the  sixth  century  A.  D.  is  also  said  to  have  successfully 
removed  certain  diseased  viscera  by  incision  through  the  abdominal  wall. 

These  stories  rest  upon  no  definite  foundation.  Acupuncture,  counter- 
irritation,  and  various  forms  of  shamjxioing  seem  to  have  been  the  only 
forms  of  surgical  treatment  practised  in  this  nation,  and  opei'ative  surgery 
is  now,  as  it  probably  always  has  been,  practically  unknown  among  the 
Chinese. 

After  the  time  of  Hippocrates  there  is  very  little  of  interest  from  a 
surgical  point  of  view  recorded  in  Greece  itself.  His  sons,  Thessalus 
and  Draco,  and  his  son-in-law,  Polybius,  were  also  physicians,  and  are 
supposed  to  be  the  authors  of  some  of  the  books  in  the  Hip]iocratic  col- 
lection. Aristotle  gave  a  strong  stimulus  to  the  study  of  anatomy,  and 
is  said  to  have  written  two  books  on  medicine,  which  have  been  lost. 
Through  the  influence  of  his  pupils  the  fomous  library,  museum,  aiid 
schools  of  Alexandria  were  formed,  and  the  headquarters  of  medical 
knowledge  for  the  time  being  passed  to  Egypt.  The  Alexandrian  School 
is  famous  for  the  advances  in  the  knowledge  of  human  anatomy  which 
were  made  there  as  a  result  of  the  authority  which  was,  for  a  short  time, 
granted  for  the  dissection  of  human  bodies.  The  numerous  writings  of 
the  anatomists  of  this  school  have  been  lost  as  distinct  works,  but  prob- 
al)ly  all  their  important  discoveries  and  teachings  have  been  preserved 
for  us  in  the  \\orks  of  Celsus,  Galen,  and  Oribasius.  Herophilus  (about 
300  B.  c.)  was  perha]is  the  most  famous  of  these  anatomists,  and  many 
of  the  names  of  parts  which  he  gave  are  in  use  to-day,  such  as  the 
choroid,  the  retina,  the  dura  and  pia  mater,  the  calamus  scriptorius,  the 
duodenum,  and  the  prostate.     Erasistratus,  his  contemporary  and  rival. 


THE  HISTORY  AXD  LITERATURE  OF  SURGERY.  29 

was  also  a  famous  anatomist,  but  we  know  oven  less  of  his  work  than  we 
do  of  that  of  Herophilns.  Galen  says  that  he  invented  the  catheter,  l)nt 
it  is  probable  that  tiiis  instrument  was  known  both  in  Egypt  and  in 
India  long  before. 

The  advances  in  surgery  made  by  the  Alexandrian  School  prior  to 
the  Christian  era  ai'e  practically  summed  up  in  the  first  treatise  on  sur- 
gery written  in  Latin  which  has  come  down  to  us — namely,  that  of  Celsns, 
or,  moi'c  properly,  of  Aulas  Cornelius  Celsus.  Of  the  personality  of 
this  writer  we  know  nothing  jxisitively,  but  he  probably  lived  at  Rome 
about  the  beginning  of  the  Christian  era,  and  was  not  a  physician  by 
profession,  medicine  at  that  time  being  almost  exclusively  practised  by 
Greeks.  He  is  quoted  by  Pliny  as  an  author  as  distinguished  from  a 
physician,  and  ids  work  was  not  referred  to  by  any  medical  writer  for 
over  a  thousand  years  after  his  death.  His  book  was  a  sort  of  encyclo- 
ptedia  of  the  arts  and  sciences  of  his  time,  intended  for  educated  men, 
but  not  specially  for  physicians,  and  the  medical  portion  consists  of 
eight  books  or  sections,  wiiich,  in  the  original,  followed  the  five  books 
of  the  treatise  on  agriculture — the  first  book  of  the  "  De  re  Medica  " 
being  in  the  oldest  Vatican  manuscript  entitled  "  Aidi  Cornclii  Celsi 
liber  sextus,  idemqne  mediciiife  primus."  After  the  invention  of  jirinting 
the  "  De  re  medica  "  of  Celsus  was  one  of  the  first  books  that  issued 
from  the  press,  having  been  published  in  1478,  since  which  date  there 
have  been  over  sixty  Latin  editions  and  translations  into  most  modern 
languages. 

Most  persons  not  familiar  with  the  history  of  the  art  are  accustomed 
to  jilace  C-elsus  with  Hijipocrates  and  Galen  as  one  of  tiie  three  great 
Fathers  of  Medicine  ;  but  he  was  really  only  a  compiler,  altliough  a 
compiler  whose  conciseness  and  clearness  of  style  have  gained  for  iiim  the 
title  of  "  the  Medical  Cicero."  As  Greek  Mas  the  professional  language 
of  his  day,  he  could  find  no  Latin  equivalent  for  many  of  the  technical 
terms,  and  was  obliged  to  use  either  a  descriptive  periphrasis  or  to  give 
the  Greek  word,  intntduced  by  the  piirase  "  the  Greeks  call  it."  He  was 
also  troubled  by  the  fact  that  in  writing  in  Latin  on  tlie  subject  of  hernia 
he  was  compelled  to  use  what  was  considered  to  be  a  very  immodest  and 
improper  word,  for  which  he  duly  apologizes ;  and  this  is  one  of  the 
numerous  pi'oofs  that  his  work  was  not  intended  for  physicians  espe- 
cially, but  for  the  educated  public. 

A  compiler  without  practical  experience  is  sure  to  make  some  mis- 
take ;  and  a  good  illustration  of  this  is  found  in  the  remarks  of  Celsus 
upon  dislocation  of  the  liip,  as  pointed  out  by  Broca.  Dislocation  of 
the  hip-joint,  prior  to  the  discoveiy  of  anassthetics  and  the  introduction 
of  Reid's  method,  was  often  very  difficult  to  reduce ;  but  after  it  had 
once  been  reduced  there  was  no  special  difficulty  in  keeping  the  head  of 
the  femur  in  its  proper  jdace.  Celsus  had  probably  never  seen  a  case, 
but  he  had  heard  that  one  of  tiie  great  dangers  is  that  when  reduceil  it 
may  slip  out  again,  this  idea  having  probably  arisen  from  confounding 
fracture  of  the  neck  of  the  femur  with  dislocation  of  its  head ;  so  he 
argues  as  follows  :  "  Some  maintain  that  it  always  does  so  [i.  e.  slips  out 
again],  but  Hippocrates,  Diocles,  Philotinus,  Xileus,  and  Heraclides  the 
Tarentine,  very  celebrated  authors,  iiave  asserted  tliat  they  have  effected 
a  perfect  cure.     Xeitlier  would  Hippocrates,  .Vndreas,  Xileus,  Xympho- 


30  THE  HISTORY  AM)  LITERATUnE  OF  SUROERY. 

dorus,  ProtarcliUf^,  Hcnu'lideH,  and  also  a  certain  nicclianician  liave 
invented  so  many  kinds  of  machines  for  extending  tlie  feninr  in  this 

case  if  it  had  been  to  no  purpose Therefore  it  must  be  attempted." 

The  logic  is  excellent,  but  the  point  which  he  supposes  to  be  in  dispute  is 
wholly  imaginary. 

Sonic  of  the  details  of  surgical  practice  given  by  Celsus  will  be  con- 
sidered in  connection  with  those  found  in  otiier  writers  next  to  be  referred 
to.  Of  these  the  chief  is  Claudius  Galen,  who  was  burn  at  Pergamus 
l;jl  A.  u.  He  studied  medicine  at  the  schools  of  Smyrna,  Corinth,  and 
Alexandria,  and  returned  to  Pergamus  at  the  age  of  twenty-eight,  when 
he  was  ai)pointed  to  the  medical  charge  of  tlic  athletes  of  the  gymnasium 
connected  with  the  temple  of  ^lllscidapius.  Four  years  later  he  went  to 
Rome,  where  he  soon  became  celebrated.  He  finally  returned  to  his 
native  country,  where  he  died  when  about  seventy  years  old.  He  is 
said  to  have  written  five  hundred  treatises  on  medicine,  but  a  lai'ge 
number  of  these  have  been  lost,  and  a  number  which  exist  in  manuscript 
have  not  been  printed. 

The  medical  system  of  Galen  is  happily  compared  by  Daremberg 
to  a  tissue  of  which  the  Hippocratic  Writings  are  the  woof  and  those 
of  Aristotle  the  ^\•arp.  His  anatomy  is  mainly  contained  in  his  treatise 
"  De  usu  partium,"  the  purpose  of  which  treatise  is  to  prove  that  all  the 
organs  of  the  body  are  arranged  in  the  best  possible  manner  and  show 
the  \\-isdom  and  care  of  Nature.  After  a  few  jjreliminary  definitions  he 
begins  his  third  section  as  follows  :  "  As  man  is  the  wisest  of  all  animals, 
so  the  hands  are  the  instruments  which  belong  to  a  wise  being.  For 
man  is  not  the  wisest  of  animals  because  he  has  hands,  so  says  Anaxa- 
goras,  but  he  has  hands  because  he  is  the  Avisest,  as  says  Aristotle,  who 
judges  very  judiciously.  In  fact,  it  is  not  by  his  hands,  but  by  his 
reason,  that  man  has  learned  the  arts.  The  hands  are  an  instrument,  as 
the  lyre  for  the  musician  or  the  pincers  for  the  blacksmith." 

Between  the  time  of  Celsus  and  that  of  Galen  there  were  three 
writers  whose  names  should  be  mentioned  in  a  sketch  of  ancient  sur- 
gery, although  their  works  have  for  the  most  part  been  lost — namely, 
Soranus  of  Ephesus,  about  79-138  A.  D.,  and  Rufus  of  Ephesus,  and 
Heliodorus,  about  the  beginning  of  the  second  century.  The  treatise 
of  Soranus  on  the  diseases  of  women,  edited  and  translated  into  Latin 
by  Ermerius,  was  published  in  1869,  and  his  "  De  signis  fracturarum  " 
was  published  by  Cocchius,  with  a  translation,  in  1754.  A  considerable 
part  of  his  medical  writings  form  the  books  ordinarily  attributed  to 
Cielius  Aurelianus.  Such  M'orks  of  Rufus  as  have  been  preserved  were 
edited  and  translated  into  French  by  Daremberg,  and  published  in  1879. 
Heliodorus  lived  at  Rome  in  the  time  of  Trajan,  about  the  beginning  of 
the  second  century  a.  d.,  and  wrote  a  treatise  on  surgery,  the  fragments 
of  \\hich,  preserved  for  us  by  Oribasius,  indicate  that  he  nuist  have  been 
a  skilful  surgeon,  well  acquainted  with  anatomy  and  with  various  modes 
of  operating  which  have  been  proclaimed  as  marvellous  in  later  days, 
such  as  the  torsion  of  arteries,  a  particular  mode  of  operating  for  the 
radical  cure  of  hernia  by  excision  of  the  sac,  the  excision  of  stricture 
of  the  urethra,  etc. 

After  Galen,  probably  about  the  end  of  the  third  century,  came  a 
surgeon  named  Antyllus,  who  seems  to  have  been  a  skilful  operator  and 


THE  HISTORY  ASD  LITERATVEE  OF  SURGERY.  31 

ail  original  writer,  luit  of  wliose  works  wu  \va\q  only  fragments  preser\-ed 
in  the  writings  of  Orihasius,  a  native  of  Pergainus,  who  was  the  physi- 
cian and  friend  of  the  emi)eror  Julian  almut  tiie  middle  of  the  fourth 
century.  Oribasius  wrote  a  huge  medieal  eyeloptedia,  whieh  formed 
seventy  books,  of  which  over  two-thirds  have  been  lost,  but  what 
remains  is  of  much  interest  in  an  historical  point  of  view,  because  he 
copied  literally,  or  nearly  so,  the  text  of  the  authors  from  whom  he 
compiled,  often  giving  their  names,  and  in  tliis  way  has  preserved  frag- 
ments of  many  works  of  which  we  have  no  otlu'r  means  of  knowledge. 

The  next  in  time  of  the  great  medieal  compilers  and  encyclop;edists 
is  iEtius  Amidenns,  who  lived  in  the  early  part  of  the  sixth  century, 
studied  medicine  in  Alexandria,  and  practised  at  Constantinople,  where 
he  became  famous.  He  wrote  a  work  in  four  books,  each  containing  four 
.sections,  which  is  known  as  the  "  Tetrabiblos."  There  are  no  translations 
into  modern  languages.  It  is  an  important  work  in  the  history  of  sur- 
gery, containing  extracts  from  previous  authors  not  found  elsewhere,  and 
it  supplements,  to  some  extent,  what  remains  to  us  of  Oribasius,  as  it 
contains  copies  of  some  of  the  lost  sections  of  that  writer.  He  describes 
charms  and  amulets,  in  which  lie  had  full  faith,  and  he  has  been  supposed 
to  have  been  a  Christian,  because  in  extracting  a  bone  he  recommends 
the  use  of  the  following  word-charm  :  "  Bone,  as  Jesus  Christ  caused 
Lazarus  to  come  out  of  the  grave,  as  Jonah  came  out  of  the  whale's 
belly,  come  out !" 

Following  aEtius,  about  the  middle  of  the  sixth  century  was  Alex- 
ander of  Tralles,  a  Lydian,  who  practised  at  Rome,  and  wrote  a  \\-ork  on 
medicine  in  twelve  l)Ooks,  the  Greek  text  of  which  was  first  published  at 
Paris  in  1548.  He  was  a  Christian,  and  made  use  of  amulets  and  incan- 
tations, of  which  he  gives  several  specimens. 

Paul  of  uEgina  (Paulus  ^Egineta),  the  last  of  the  Greek  writers  ou 
medicine,  lived  in  the  early  part  of  the  seventh  century  and  studied  at 
Alexandria.  His  seven  books  are  among  the  most  famous  of  medical 
classics,  and  form  a  compend  and  abridgment  of  the  medical  literature 
of  his  day  carefully  selected  and  concisely  expressed.  His  main  source 
of  information  appears  to  have  been  the  works  of  Oribasius.  He  does 
not  pretend  to  any  originality,  as  will  be  seen  by  the  following  extract 
from  his  preface:  "It  is  not  because  the  more  ancient  writers  had  omitted 
anything  in  the  art  that  I  have  composed  this  work,  but  in  order  to  give 
a  continuous  course  of  instruction  ;  for,  on  the  contrary,  everything  is 
handled  l)y  them  properly  and  without  any  omissions,  whereas  the 
moderns  have  not  only  in  the  first  place  neglected  the  study  of  them, 

but  have  also  blamed  them  for  prolixity To  remember  all  the 

rules  of  the  healing  art  and  all  the  particular  substances  connected  with 
it  is  exceedingly  difficult,  if  not  altogether  impossible.  On  this  account 
I  have  comjiiled  this  brief  collection  from  the  works  of  the  ancients,  and 
have  set  down  little  of  my  own,  except  a  few  things  which  I  have  seen 
and  tried  in  the  practice  of  the  art."  I'he  sixth  book  is  a  system  of 
operative  surgery,  the  most  complete  of  any  which  have  come  to  us  from 
before  his  time,  and  the  source  of  most  of  the  surgical  treatises  of  Arabian 
authors.     In  it  he  never  refers  to  Celsus,  but  often  to  Galen. 

Having  thus  given  a  brief  account  of  the  principal  Greek  and  Latin 
writers  on  surgery  whose  works  are  known  to  us,  we  may  now  consider 


32  THE  HISTORY  AND  LITERATURE  OF  SURGERY. 

tlie  progress  in  the  art  wliich  lincl  l)con  made  between  tlie  time  of  Hi])])oc- 
rates  and  tliat  of  Paul  of  ^'Eo-ina,  a  period  of  ahout  one  tlionsand  years. 

First,  as  to  hemorrhage  from  recent  wonnds,  and  more  especially 
arterial  hemorrhage.  Upon  this  snbject  the  Hijjpocratic  Writings  contain 
nothing.  C'elsus  says  (lib.  v.  cap.  xxvi.) :  "If  we  fear  the  hemorrhage, 
the  wound  is  to  be  filled  with  dry  pledgets  of  lint,  and  a  sponge  squeezed 
out  of  cold  water  is  to  be  applied  and  eom])res,sed  with  the  hand.  If  the 
blood  still  issues,  the  lint  must  be  changed  frequently,  and  if  dry  lint 
does  not  succeed,  it  should  be  moistened  with  vinegar.  Caustics  slaould 
not  be  used,  except  in  urgent  cases,  on  account  of  the  inflammation 
which  follows  their  use.  If  compression,  cold,  and  vinegar  fail  to  stop 
the  bleeding,  the  vessels  which  pour  out  the  bhxtd  are  to  be  seized  and 
tied  with  two  ligatures,  one  on  each  side  of  the  wounded  ])art,  after  which 
the  vessels  are  to  be  di\'ided  between  the  ligatures,  that  tliey  may  retract 
and  still  have  the  openings  closed.  If  the  case  does  not  admit  of  this, 
the  actual  cautery  may  be  used."  Celsus  makes  no  reference  here  to  any 
distinction  between  arterial  and  venous  hemorrhage.  In  speaking  of 
castration  he  says  :  "  The  veins  and  arteries  nnist  be  secured  by  a  liga- 
ture at  the  groin  and  divided  behind  it."  This  is  the  first  mention  of 
the  ligature  of  blood-vessels  in  published  literature  :  it  was  an  invention 
of  the  Alexandrian  School,  and  is  said  to  have  been  introduced  at  Rome 
by  Euelpistus,  who  lived  a  short  time  before  Celsus. 

Galen  refers  in  several  places  to  the  use  of  the  ligature,  but  treats 
more  especially  of  hemorrhage  in  the  fifth  book  of  the  Alcthodus  Medendi. 
He  directs  that  the  finger  be  placed  gentlv  upon  the  mouth  of  the  bleed- 
ing vessel,  extending  and  compressing  it.  If  the  wounded  vessel  lies 
deep,  the  surgeon  must  thus  learn  its  position  and  size,  and  then,  whether 
it  be  a  vein  or  an  artery,  lift  it  with  a  hook  and  twist  it  a  little.  If'this 
does  not  answer  and  it  is  a  vein,  styptics,  such  as  roasted  rosin,  fine 
flour,  gypsum,  etc.,  are  to  be  tried  ;  but  if  it  is  an  artery,  it  must  be  either 
ligated  or  entirely  divided.  Sometimes  the  veins  must  also  be  ligated 
and  divided ;  but  it  is  safer  to  do  both — that  is,  to  ligate  the  proximal 
end  of  the  vessel  and  also  to  divide  it  beyond  the  ligature.  Oribasius 
says  nothing  about  the  ligature,  but  advises  the  cautery  if  the  bleeding 
cannot  be  checked  otherwise.  Paulus  ^Egineta  copies  Galen  almost 
literally,  but  says,  in  addition  :  "  You  may  know  whether  it  is  a  vein  or 
an  artery  that  pours  fortii  the  blood  from  this,  that  the  bloixl  of  an  artery 
is  brighter  and  thinner  and  is  evacuated  by  pulsations,  whereas  that  of 
the  vein  is  blacker  and  without  pulsation." 

While  it  is  thus  evident  that  the  use  of  the  ligature  was  known  from 
the  beginning  of  the  Christian  era,  it  is  curious  that  it  seems  never  to 
have  been  employed  to  check  hemorrhage  from  vessels  divided  in  ampu- 
tations. 

Celsus  remarks  that  in  cases  of  gangrene  of  an  extremity  the  incision 
is  to  be  made  between  the  sound  and  the  corrupted  part,  but  says  nothing 
about  details.  Galen's  advice  is  the  same  as  that  of  Hippocrates.  Paulus 
says  :  "  Leonides  properly  directs  us  not  to  divide  all  the  parts  at  once 
unless  they  are  completely  mortified,  but  first  to  cut  the  part  where  not 
many  nor  \-ery  large  veins  or  arteries  are  known  to  be  situated,  down  to 
the  bone  quickly  ;  then  to  saw  the  bone  as  rapidly  as  j)0ssible,  applying 
a  linen  rag  to  the  parts  which  have  been  cut,  lest  they  be  torn  by  the 


THE  HISTORY  AND  LITERATURE  OF  SURGERY.  33 

saAving  and  cause  pain,  and  then,  havinti'  out  tlirougli  what  remains,  to 
apply  red-iiot  irons  to  the  vessels,  and  stop  the  lieim)rrhage  thereby  with 
compresses  of  lint."  The  Leonides  referred  to  here  was  an  Alexandrian 
surgeon  who  lived  about  the  beginning  of  the  third  century  a.  d.  Prior 
to  this,  however,  Archigenes,  a  celebrated  physician  mIio  lived  at  Rwme 
al)out  the  beginning  of  the  second  century  A.  D.,  and  Heliodorus,  had 
given  more  details  as  to  methods  of  ami)utation,  as  appears  from  the 
fragments  of  their  works  preserved  in  the  collection  of  Nieetas,  ])ublisiied 
bv  Cocchius  in  1756.  Archigenes  apjicars  to  have  connnenccd  tiie  opera- 
tion in  some  cases  by  a  preliminary  ligature  of  the  blood-\'essels  supply- 
ing the  parts ;  the  incision  was  a  circular  sweep  down  to  the  bone.  The 
red-hot  iron  was  used  to  check  hemorrhage.  The  method  of  Heliodorus 
is  substantially  the  same  as  that  of  Leonides. 

Aneurism  is  not  mentioned  by  Hippocrates  or  by  Celsus.  Galen 
describes  it  in  his  work  "  De  tnmoribus,"  saying  that  it  may  arise 
either  from  simple  dilatation  or  from  a  wound  of  an  artery,  and  is 
recognized  by  its  pulsation.  The  only  treatment  he  refers  to  is  com- 
pression by  means  of  sponge. 

The  following  is  an  extract  from  the  treatise  of  Antyllus  on  aneurism, 
as  given  by  Oribasius  :  "  There  are  two  kinds  of  aneurysm.  In  the  first 
the  artery  has  undergone  a  local  dilatation  ;  in  the  second  the  artery  has 
been  ruptured.  The  aneurysms  which  arc  due  to  dilatation  are  longer 
than  the  others.  The  aneurysms  by  rupture  are  more  rounded.  To 
refuse  to  treat  any  aneurysm,  as  the  ancient  surgeons  advised,  is  unwise  ; 
but  it  is  also  dangerous  to  operate  upon  all  of  them.  We  should  refuse, 
therefore,  to  treat  aneurysms  which  are  situated  in  the  axilla,  in  the 
groin,  and  in  the  neck,  by  reason  of  the  volume  of  the  vessels  and  the 
impossil)ility  and  danger  of  isolating  and  tying  them.  We  should  not 
touch  an  aneurysm  of  large  volume  even  when  it  is  situated  in  some 
other  part  of  the  body.  We  operate  in  the  following  manner  ujjon 
those  which  are  situated  upon  the  extremities  and  the  head  :  If  the 
aneurysm  be  by  dilatation,  make  a  straight  incision  through  the  skin  in 
the  direction  of  the  length  of'the  vessel,  and,  drawing  open  by  the  aid  of 
hooks  the  lips  of  the  wound,  divide  with  precautions  the  membranes  which 
cover  the  artery.  With  blunt  hooks  we  isolate  the  vein  from  the  artery,  and 
lay  bare  on  all  sides  the  dilated  part  of  this  last  vessel.  After  having 
introduced  beneath  the  artery  a  probe,  we  raise  the  tumor  and  pass  along 
tlie  probe  a  needle  armed  with  a  double  thread  in  such  a  manner  that 
this  thread  finds  itself  placed  beneath  the  artery ;  cut  the  threads  near 
the  extremity  of  the  needle,  so  that  there  will  be  two  threads  having 
four  ends ;  seizing,  then,  the  two  ends  of  one  of  these  threads,  we  bring 
it  gently  toward  one  of  the  two  extremities  of  the  aneurysm,  tying  it 
carefully ;  in  like  manner  also  we  bring  the  other  thread  toward  the 
opposite  extremity,  and  in  this  place  tie  the  artery.  Thus  the  whole 
aneurysm  is  between  the  two  ligatures.  We  open  then  the  middle  of 
the  tumor  by  a  small  incision  :  in  this  manner  all  which  it  contains  will 
be  evacuated,  and  there  will  be  no  danger  of  hemorrhage. 

"  To  tie,  as  it  has  l)cen  advised,  the  artery  on  both  sides  the  vein,  and 
then  to  extirpate  the  dilated  part  which  finds  itself  between,  is  a  dan- 
gerous operation  ;  frequently,  in  fact,  the  violence  and  tension  of  the 
arterial  pneuma  push  off  the  ligatures. 

Vol.  I.— 3 


34  THE  HISTORY  AND  LITEIiATUllK  OP'  SURriERY. 

"If"  the  aiu'iirysm  owes  its  origin  t(j  tlie  ni|)tiii'C'  ni'  tlio  artery,  we 
isolate  witii  tlie  fingers  as  much  of  the  tumor  as  we  can,  inckiding  the 
skin,  after  wliich  we  jiass  uiiderneatli  the  isolated  part  the  needle  Mith 
the  double  thread  and  proceed  as  before ;  after  which  the  tumor  may  be 
opencil  at  its  summit  and  tlie  supcrflnous  jiortion  of  the  skin  cut  away." 

Upon  injuries  of  tlic  skull  and  trepliining  C'elsus  s])eaks  at  consider- 
able lengtli,  (|Uoting  fully  from  Hippocrates.  To  distinguish  a  fissure 
from  a  suture  he  advises  the  pouring  of  ink  (jn  the  part  and  then  scraping 
the  bone ;  if  there  is  a  fissure,  the  ink  will  mark  it.  He  says  that  if 
blood  is  extravasated  beneath  the  cranium,  tiie  overlying  bone  will  be 
pale.  If  no  dangerous  symptoms  come  on,  he  would  defer  o])erating  on 
the  bone  for  five  days.  All  depressed  l)one  is  to  be  removed,  but  no 
more  is  to  be  taken  away  than  is  necessary.  Galen  preferred  the  use  of 
small  gouges,  and  of  an  instrument  called  a  lenticular,  to  that  of  the 
trephine.  He  says  that  all  greatly  bruised  (and  depressed)  bone  is  to  be 
removed,  but  that  simple  fissures  do  not  require  operation.  Paulus  co])ies 
Galen.  It  will  be  seen  that  the  Greek  and  Roman  metliods  did  not  differ 
greatly  from  those  of  the  present  day. 

In  fractures  of  the  spine  Paulus  says  that,  "  having  first  given  warn- 
ing of  the  danger,  w'e  must,  if  possible,  attempt  to  extract  by  an  incision 
the  compressing  bone,"  and  that  the  same  is  to  be  done  in  case  of  frac- 
ture of  one  of  the  spinous  jirocesses. 

Celsus  (lib.  v.  cap.  xxviii.)  describes  carcinoma  as  usually  occurring 
about  the  face,  and  in  the  Ijreasts  of  females,  but  says  that  it  may  also 
occur  in  the  liver  or  spleen.  It  is  the  seat  of  some  lancinating  pains,  is 
tumefied,  immovable,  and  unequal,  and  the  veins  about  it  are  swollen 
and  tortuous.  It  commences  by  what  the  Greeks  call  cacoethes,  then 
proceeds  to  carcinoma  or  scirrhus  without  idceration,  then  to  an  ulcer 
which  becomes  fungous.  "  None  of  these  can  be  removed  except  the 
cacoethes ;  the  rest  are  aggravated  by  every  method  of  treatment,  and 

the  more  energetic  the  remedies  the  more  irritable  they  become 

None  were  ever  treated  successfully  with  medicine  ;  .  .  .  .  after  excision, 
though  a  cicatrix  has  been  formecl,  they  have  returned  again  and  carried 

off  the  patient But  no  one  can  distinguish  a  cacoethes,  which  is 

curable,  from  a  carcinoma,  which  is  incurable,  except  by  time  a'nd 
experiment." 

Galen  describes  cancer  at  greater  length,  Init  adds  nothing  to  the 
means  of  tliagnosis  :  the  only  chance  of  cure  lies  in  excision,  but  if  this 
be  performed  the  arteries  must  not  be  tied. 

Paulus  merely  abridges  Galen's  description,  says  nothing  about  an 
operation,  and  advises  external  applications.  A  hard  tumor  which  is 
wholly  insensible  is  incurable. 

Cystic  tumors,  including  atheroma,  meliceris,  and  steatoma,  are  briefly 
but  cleai-ly  described  by  Celsus  (lib.  vii.  cap.  vi.) ;  they  are  to  be  removed 
by  incision  :  in  steatoma  the  cyst  must  be  divided,  in  the  others  it  may 
be  removed  entire.  Antyllus  gives  a  more  detailed  description,  which 
is  quoted  by  Oribasius  (lib.  xlv.). 

The  Hijipocratic  oath  requires  that  litliotomy  be  left  to  those  who 
make  a  special  business  of  it.  The  first  author  ^\•ho  describes  the  opera- 
tion is  Celsus  (lib.  vii.  cap.  xxvi.).  He  says  it  should  only  be  performed 
in  the  spring,  and  on  children  Ijetween  the  ages  of  nine  and  fourteen,  and 


THE  HISTORY  AND  LITERATURE  OF  SURGERY.  35 

in  urgent  cases  when  metlieines  have  failed,  althongli  he  admits  that  a 
rasli  operation  now  and  then  succeeds.  The  toleration  described  is  that 
which  is  commonly  known  as  "cutting'  on  the  gripe,"  or,  in  modern 
times,  as  the  "  Celsian  t)peration."  The  description  given  by  Celsus  is 
detailed,  and  in  most  points  is  very  clear  (lib.  vii.  cap.  xxvi.).  The  essen- 
tial principle  is  to  force  the  stone  down  into  the  neck  of  the  bladder  and 
hold  it  there  by  two  fingers  introduced  into  the  rectum,  after  wliich  a 
lunatcd  incision  is  to  be  made  through  the  skin  of  the  perineum  imme- 
diately over  and  extending  to  the  neck  of  the  bladder,  and  a  second 
incision  in  the  convex  part  of  the  wound,  so  as  to  open  the  neck  of  the 
bladder  freely ;  and  the  wound  should  be  a  little  larger  than  the  calculus, 
for  those  who  dread  a  fistula  make  too  small  an  opening,  and  are  after- 
ward I'educed  to  the  same  inconvenience  with  still  greater  danger,  because 
the  calculus  when  forced  will  make  a  passage  unless  it  find  one;  and  this 
is  even  still  more  injurious  if  the  form  and  inequalities  of  surface  have 
contributed  in  any  way  to  this  effect.  If  the  stone  is  so  large  that  it 
cannot  be  extracted  without  lacerating  the  neck  of  the  bladder,  it  must 
be  split  according  to  the  method  of  Ammonius,  who  was  known  as  Lith- 
otomus,  the  stone-cutter.  It  is  done  in  this  manner:  A  crotchet  is  intro- 
duced to  the  calculus,  so  as  to  hold  it  fast  while  being  struck,  lest  it 
shoukl  recoil  backward  ;  then  an  ii'on  instrument  of  moderate  thickness 
is  to  be  employed,  the  one  extremity  of  which  is  thin,  but  blunt,  and 
being  ajiplied  to  the  stone  and  struck  at  the  other  extremity,  splits  it, 
great  care  being  taken  that  neither  the  instrument  itself  nor  any  frag- 
ment of  the  stone  should  injure  any  part. 

There  is  practically  nothing  to  add  to  this  description  by  other  Greek 
writers  until  we  come  to  the  time  of  Paulus,  whose  description  is  much 
the  same  as  that  of  Celsus.  He  says  that  children  up  to  the  age  of  four- 
teen are  the  best  subjects  for  the  operation  :  old  men  are  difficult  to  cure, 
because  ulcers  of  their  body  do  not  readily  heal,  and  intermediate  ages 
have  an  intermediate  chance  of  recovery.  The  stone  is  to  be  brought 
down  I)y  the  fingers  in  the  rectum,  as  described  above;  then  "we  take 
the  instrument  called  a  lithotome,  and  between  the  anus  and  the  testicles 
— not,  however,  in  the  middle  of  the  perineum,  but  on  one  side,  toward 
the  left  buttock — we  make  an  oblique  incision,  cutting  down  direct  upon 
the  stone  where  it  protrudes,  so  that  the  external  incision  may  be  wider, 
but  the  internal  not  larger  than  just  to  allow  the  stone  to  fall  through  it. 
Sometimes,  from  the  pressure  of  the  finger  or  fingers  at  the  anus,  the 
stone  starts  out  readily  at  the  same  time  tliat  the  incision  is  made,  with- 
out requiring  extraction  ;  but  if  it  does  not  start  out  of  itself,  we  must 
extract  it  with  the  forceps  called  the  stone-extractor."  .  ..."  If  the 
stone,  being  small,  fall  into  the  penis  and  cannot  be  voided  with  the  urine, 
we  may  draw  the  prepuce  strongly  forward  and  bind  it  at  the  extremity 
of  the  glans.  We  must  next  ajiply  another  ligature  round  the  penis  behind 
the  menil)er,  making  tlie  eonstriction  at  its  extremity  next  the  bladder, 
and  then  make  an  incision  down  upon  the  stone,  and,  bending  the  penis, 
we  eject  the  stone,  and  undoing  the  ligatures  we  clear  away  the  coagula 
from  the  wound.  Tiie  posterior  ligature  is  applied  lest  the  calculus 
should  retreat  backward,  and  the  anterior  in  order  that,  when  untied 
after  the  extraction  of  tlie  stone,  the  skin  of  the  prepuce  may  slide  back- 
ward and  cover  the  incision." 


36  THE  HISTORY  AM)  I.ITKnATVRE  OF  SURGERY. 

Aftei'  the  capture  of  Alexandria  by  tlie  newly-risen  Mohaniniedau 
power,  about  640  A.  D.,  the  Arabians  became  the  inheritors  and  preservers 
of  the  science  of  the  Greeks.  The  first  notions  of  medicine  obtained  by 
the  Arabs  were  proliably  derived  from  Persia,  if  we  may  judge  by  the 
names  of  a  great  number  of  tlieir  drug;s,  and  the  medical  knowledge  of 
Persia  came  in  part  from  India  and  in  j)art  from  Greece. 

The  first  Arab  physician  of  note  was  Hareto  Ben  Coladoh,  who  lived 
about  the  middle  of  the  sixth  century,  and  who  seems  to  have  studied 
medicine  under  the  Nestorians,  a  Christian  sect  dating  from  the  early 
part  of  the  fifth  century  and  occupying  the  ancient  countries  of  Assyria 
and  Persia.  The  Nestorian  physicians  appear  to  \vA\e  been  very  zealous 
in  collecting  and  ])rcserving  all  the  medical  works  which  could  be  found 
at  that  time,  including  those  of  the  Hippoci'atic  collection  and  the 
writers  of  the  Alexandrian  School.  In  the  mean  time,  after  the  destruc- 
tion of  Jerusalem,  certain  Jewish  physicians  and  teachers  had  settled  in 
Alexandria,  and  after  the  fall  of  that  city  we  find  some  of  these  Jewish 
physicians  taking  somewhat  jirominent  positions  and  being  collectors 
and  translators  of  the  medical  literature  of  the  Greeks.  The  so-called 
"  Arabic  books  on  medicine  "  were  largely  compends  and  summaries  of 
the  works  of  Greek  writers  which  had  been  translated  into  Syriac  or 
into  Hebrew,  and  thence  into  Arabic,  or,  in  some  few  cases,  directly  into 
Arabic.  There  are  very  few  of  these  which  contain  any  matter  of  interest 
to  the  history  of  surgery. 

The  most  famous  of  their  writers  was  Avicenna  (980-1036  A.  D.),  a 
native  of  Persia,  who  for  five  hundred  years  rivalled  Galen  as  an  authority, 
and,  like  him,  was  called  the  Prince  of  Physicians.  The  medical  works 
of  Avicenna,  known  as  "  The  Canon,"  are  a  sort  of  encyclopaedia,  in 
which  the  opinions  of  the  Greeks  and  of  Galen  ai'e  mingled  M'itli  Oriental 
philosophy,  forming  a  very  jirolix  and  in  many  places  obscure  treatise 
upon  all  subjects  connected  M'ith  medicine.  It  was  translated  into  Latin 
by  Gerard  of  Cremona,  and  became  for  a  time  the  principal  guide  for 
European  jjhysicians,  its  high  repute  being  probably  due  in  part  to  the 
diflieulty  of  imderstanding  it. 

The  most  celebrated  writer  on  surgery  of  the  Arabian  School  was 
Albucasis,  also  known  as  Bulchasis,  Abulcasis,  or  Alsaharavius,  and 
properly  as  "  Khalaf  Ibn  'Abbas  (Abu  Al-Kasim)  Al-Zahrawi."  He 
was  born  at  Zahra,  near  Cordova,  and  died  about  1105  A.  D.  His  great 
work,  Al  Tesrif  or  Tasrif — /.  e.  the  collection  or  encyclopaedia — included 
thirty  books  upon  all  branches  of  medicine,  but  of  these  only  a  part  have 
ever  been  published.  The  three  books  of  his  works  on  surgery,  forming 
a  special  treatise  (book  xxx.  of  Al  Tesrif),  were  published  in  Arabic  and 
Latin  under  the  editorship  of  John  Channing  at  ()xford  in  1778,  and 
this  is  the  best  printed  edition  which  is  available,  although  in  some 
respects  it  is  obscure  and  unsatisfactory.  A  translation  into  French  A^'as 
made  l)y  Dr.  Leclerc  and  puldished  in  the  Gazette  iiifdicale  de  rAlr/erie 
in  1858-61,  and  afterward  issued  as  a  rejn'int  (Paris,  1861);  and  this  is 
the  most  convenient  edition  to  consult  for  most  purposes. 

The  work  is  divided  into  three  books.  The  first  is  devoted  to  the 
actual  cautery  and  the  use  of  caustics,  with  elaborate  descriptions  of  the 
instruments  Avhich  are  figured.  In  fiict,  Albucasis  is  the  first  author 
whose  works  have  come  down  to  us  who  has  given  figures  and  good 


THE  HISTORY  AXD  LITERATURE  OF  SURGERY.  37 

descriptions  of  surgical  instruments.  The  second  book  relates  to  incisions 
of  all  kinds,  bloodletting,  scarification,  treatment  of  wounds,  and  the 
extraction  of  arro\vs  and  missiles,  and  the  third  is  devoted  to  the  treat- 
ment of  fractures,  luxations,  sprains,  etc. 

The  treatise  in  general  is  a  clear  and  comparatively  concise  statement 
of  methods  of  treatment.  A  large  part  of  it  is  evidently  derived  from 
Paul  of  ^Egina  or  from  the  original  authorities  from  which  Paul  of 
..Egina  copied,  and  it  is  hard  to  say  how  much  of  his  work  is  really 
original ;  but  it  was  the  highest  authority  on  the  subjects  of  which  it 
treats  during  the  period  of  the  revival  of  letters  in  Western  Europe, 
and  is  a  very  important  work  for  the  student  of  the  history  of  surgery 
or  of  surgical  operations.  The  following  are  some  specimens  of  his 
teachings : 

In  speaking  of  the  operation  of  arteriotomy  upon  the  temporal 
arteries  he  directs  that  a  portion  of  the  vessel  be  cut  out,  so  that  the 
t\\o  ends  may  separate  in  order  to  prevent  hemorrhage.  If  the  artery 
is  large,  it  is  necessary  to  tie  it  in  two  places — at  two  points — with  a 
strong  double  thread  of  silk  or  of  the  cord  used  in  instruments  of  music 
(catgut),  in  order  that  it  may  not  alter  before  cicatrization  takes  place, 
which  would  bring  on  a  hemorrhage.  This  ligature  sliould  be  double, 
and  the  operator  is  to  take  away  the  intermediate  part,  either  at  the 
time  or  later. 

In  speaking  of  the  operation  on  scrofulous  tumors  of  the  neck  he 
says :  "  The  tumor  must  be  removed  little  by  little,  great  care  being 
taken  not  to  cut  the  blood-vessels  or  the  nerves.  If  a  vein  or  an  artery 
is  injured,  so  that  the  hemorrliage  is  troublesome  or  hinders  the  operation, 
put  into  the  w(.)und  some  vitriol  in  powder  or  some  kind  of  haemostatic 
l)i)wder;  bandage  the  wound,  and  leave  it  until  the  inflammation  lessens 
and  the  wound  tends  to  putrefaction.  Then  the  hemorrhage  will  cease 
and  you  may  go'  on  to  complete  your  operation." 

He  says :  "  The  ancients  have  spoken  of  opening  the  trachea,  but 
I  have  not  known  any  one  in  our  country  who  has  practised  this  opera- 
tion. If  the  operation  has  lieen  decided  upon,  the  incision  should  be 
made  below  the  third  or  fourth  ring  of  the  trachea  transversely  between 
the  two  rings,  so  as  not  to  injure  the  cartilages,  but  only  to  divide  the 
membrane  between  the  rings.  I  have  seen  a  slave  who  had  cut  his 
throat  with  a  knife.  On  examining  the  wound  a  little  blood  escaped,  but 
I  found  that  neitlier  the  jugular  vein  nor  the  artery  had  been  injured. 
Tiie  air  came  out  by  the  wound  ;  I  dressed  it  and  he  was  cured,  and 
only  a  little  hoarseness  of  voice  followed.  I  feel,  therefore,  authorized 
to  say  that  incision  of  the  trachea  is  without  danger." 

In  speaking  of  aneurism  he  says:  "As  to  the  tumors  which  result 
from  the  enlargement  of  tlie  calil^re  of  the  artery,  a  longitudinal  incision 
should  Ije  made  over  the  skin.  Eidarge  the  opening  with  hooks,  dissect 
the  arterv,  free  it  from-  the  meinl)i'anes  which  surround  it,  and  lay  it 
completely  l)are  ;  then  introduce  below  it  a  needle  with  a  double  thread 
and  make  a  double  ligature  of  the  vessel,  as  we  have  recommended  for 
the  excision  of  the  temporal  artery ;  then  plunge  a  knife  into  the  part 
of  the  vessel  included  between  the  two  ligatures,  and  press  out  all  the 
l)l(iod  which  is  contained  therein,  until  the  tumor  has  disappeared, 
employing  after   this  the  treatment  which   leads  to  suppuration   until 


38  THE  HISTORY  AND  LITKRATURE  OF  SURGERY. 

tlie  ligatures  fall."  It  will  be  swii  tliat  this  is  a  cojiy  ul'  the  description 
of  the  operation  of  Antvlhis. 

In  speaking  of  the  removal  of  (X'rtain  fungoid  abdominal  tumors 
resembling  mushrooms  he  directs  that  a  leaden  wire  be  used  to  strangle 
the  growths,  the  wire  being  drawn  tighter  and  tighter  from  dav  to  day, 
so  as  gradually  to  penetrate  the  root  of  the  tumor,  so  that  it  mav  fall 
without  difficulty.  He  says:  "  Refrain  from  attempting  to  excise  tumors 
which  are  of  a  livid  color,  of  slight  sensibility,  and  of  an  irregular  aspect, 
for  these  tumors  are  cancerous."  Elsewhere  he  says  :  "  If  the  cancer  is 
situated  in  a  region  from  which  it  can  be  entirely  removed,  such  as  the 
breast,  the  thigh,  etc.,  and,  above  all,  if  it  has  had  its  conunencement 
little  developed,  one  may  operate  on  it ;  if,  on  the  contrary,  it  is  large 
and  old,  it  is  necessary  to  refrain.  For  my  pai't,  I  have  never  been  able 
to  cure  a  single  one.     I  have  never  seen  any  one  who  has  succeeded." 

His  description  of  the  operation  of  the  removal  of  calculus  of  the 
bladder  is  substantially  the  same  as  that  given  by  Celsus. 

In  the  case  of  a  vesical  calculus  in  a  woman  he  says  that  if  you  are 
obliged  to  treat  such  a  case,  you  must  find  a  woman  \\'\i\\  some  skill  in 
medicine,  but  there  are  very  few  of  them.  If  you  cannot  find  such,  it 
is  necessary  to  take  a  midwife,  or,  at  all  events,  a  woman  who  knows  a 
little  something  about  the  matter.  This  woman  is  to  perform  the  opera- 
tion under  the  direction  of  the  surgeon,  according  to  the  method  which 
he  gives  in  detail. 

While  the  arts  and  sciences  were  more  or  less  prosperous  and  pro- 
gressive in  the  countries  under  Mohammedan  rule,  and  especially  in 
Spain,  throughout  the  rest  of  Europe  medicine  was  substantially  in  the 
condition  in  which  it  exists  in  barbarous  tribes.  With  the  rise  of  the 
monkish  orders,  and  especially  of  the  order  of  St.  Benedict,  the  priests 
became  the  practitioners,  and  all  progress  or  improvement  was  practi- 
cally at  an  end.  Relics,  exorcisms,  and  prayers  were  more  and  more 
relied  upon  ;  the  teachings  of  Hijipocrates  and  Galen  were  for  the  most 
part  forgotten.  The  great  majority  of  the  monks  read  nothing  but 
simple  formularies  and  receipt-books.  The  kings  and  the  great  nobles, 
including  some  of  the  bishops,  resorted  to  Hebrew  physicians,  who 
during  the  tenth  and  eleventh  centuries  were  almost  the  only  jiersons 
who  possessed  medical  learning  or  who  wrote  u|)on  nu'dical  subjects.  A 
Jewish  physician  in  those  days  was  a  sort  of  contraband  luxury.  On 
account  of  his  religion  he  could  only  be  possessed  by  those  who  had  suf- 
ficient power  to  protect  him  from  mobs  and  monks ;  but  both  Catholic 
and  Mohammedan  rulers  resorted  to  him  when  anything  like  scientific 
knowledge  was  recpiired.  Rabbi  Isaac  was  the  medical  adviser  of  Pope 
Boniface  VIII. ,  and  the  physician  of  Saladin  was  Rabbi  Ben-]\Ioosa, 
better  known  as  Moses  Maimonides,  \\ho  was  one  of  the  most  celebrated 
authors  of  his  race  and  time  (1136-1209  A.  D.).  It  should  be  noted  that 
the  preference  was  for  Jewish  jihysicians  as  being  Jews.  For  instance, 
Francis  I.,  being  sick,  wrote  to  Charles  V.  for  an  Israelite  who  was 
an  imperial  physician.  Accordingly,  the  doctor  was  sent  to  Paris,  but 
Francis,  finding  that  he  had  been  conyerted  to  Christianity,  lost  all  con- 
fidence in  his  skill  and  advice,  and  applied  to  Solyman  II.,  who  sent  him 
a  true,  original,  hardened  Jew,  follo\ving  whose  advice  he  drank  asses' 
milk  and  recovered. 


THE  HISTORY  Ayi)  LITERATURE  OF  SURGERY.  39 

Surgery  was  for  the  most  part  abandoned  to  barbers,  bathers,  and 
seventh  sons,  and  fell  into  disrepute.  These  barbers  and  bathers  were 
considered  to  be  of  inferior  caste,  and  an  artisan  would  not  take  an  ap- 
prentice of  a  family  of  barbers,  bath-keepers,  she])herds,  or  butchers. 
The  operators  were  often  peripatetic  and  were  sulnlividcd  into  specialists. 
For  instance,  one  operated  for  hernia,  another  foi-  calculus,  a  third  for 
cataract,  etc.,  the  knowledge  being  handed  down  from  father  to  son,  as 
among  the  Greeks. 

There  were  no  European  writers  upon,  or  teachers  of,  surgery  until 
the  time  of  the  rise  of  the  universities  in  Italy  in  the  thirteenth  century. 
The  ScIkioI  of  Salernum  was  probably  in  existence  in  the  ninth  century, 
the  ancient  legend  being  that  it  was  founded  by  four  men — a  Jew,  a 
Greek,  an  Arab,  and  an  Italian — each  of  whom  gave  lessons  in  his  own 
language. 

About  the  ycai-  1060  A.  D.  there  came  to  this  school  a  certain  Constan- 
tine,  generally  known  as  "  Constantinus  Africanus."  Constantine  was  a 
native  of  Carthage,  and  had  studied  in  Arabia,  India,  and  Egypt,  after 
Avhich  he  travelled  extensively  for  over  thirty  years.  Returning  to  Car- 
thage and  bringing  with  him  copies  of  all  the  works  of  the  Greek  and 
Arab  writers  which  he  had  been  able  to  obtain  in  his  travels,  he  fell  under 
the  suspicion  of  knowing  more  than  it  was  at  that  time  considered  proper 
for  any  man  to  know,  and  it  was  with  some  difficulty  that  he  escajied  the 
jiunishment  then  in  vogue  for  such  criminals.  He  fled  for  refuge  to 
Salernum,  where  he  was  received  with  honors,  which,  however,  he  put 
aside,  and  retired  to  the  neighboring  monastery  of  Monte  Casino,  where 
he  spent  the  rest  of  his  life  in  translating  and  annotating  the  medical 
works  which  he  had  collected.  These  translations  became  the  text-books 
of  the  Salcrnitan  doctors,  and  in  the  next  century  the  school  was  resorted 
to  from  all  parts  of  Eurojie  by  those  who  had  heard  of  these  long-lost 
and  forcrotten  treasures  of  learning,  which  at  that  time  were  far  in  advance 
of  the  existing  knowledge  of  the  ordinarj-  practitioners.' 

The  doctrines  of  the  school  liecame  more  and  more  Arabic,  and  it  had 
lost  its  importance  in  the  fourteenth  century,  having  lieen  superseded  by 
the  schools  of  Xaples,  Bologna,  Paris,  and  Montpellier. 

At  the  beginning  of  the  thirteenth  century  comes  the  first  writer  on 
surgery  in  the  West — namely,  Roger  of  Parma,  whose  work  was  first 
printed  at  Venice  in  1490,  and  is  included  in  several  editions  of  the 
works  of  Guy  de  Chauliac.  The  Surgery  of  Roger  is  substantially  the 
sixth  book  of  Paul  of  ^Egina.  Following  him  came  his  pupil  and  com- 
mentator, Roland,  who  was  also  of  Parma.  His  w<irk  is  a  copy  of  that 
of  Roger,  with  notes  and  some  references  to  Hippocrates,  Galen,  and 
Avicenna  which  do  not  appear  in  the  work  of  his  master. 

The  story  of  the  Four  Masters,  as  told  by  Quesnay,  is  a  romantic 
one — /.  e.  that  they  devoted  their  lives  to  the  care  of  the  sick  poor  in 
Paris,  their  residence  being  a  sort  of  surgical  dispensjuy  ;  that  they  made 
many  discoveries  and  improvements  which  they  described  in  a  book 
which  was  known  to  Guy  de  Chauliac,  but  lias  been  lost ;  etc.     Several 

■  For  a  full  aiul  interesting  discussion  of  the  writings  of  Constantine  and  tlie  authors 
copied  and  abridged  by  him,  considt  "  Constantinus  Africanus  und  seine  Arabischen 
Quellen,"  von  M.  Steinschneider,  Archiv  f.  path.  Anat.  (Virchow),  1866,  vol.  xxivii.  p. 
361. 


40  THE  HISTORY  AND  LITERATURE  OF  SURGERY. 

manuscript  copies  of  this  worlv  are  now  l^nown  to  exist,  and  in  1859  one 
of  these  was  edited  by  Daremhcrj;;  and  ])ul)lislR'd. 

The  history  of  surgery  in  Eurojie  tlius  begins  in  Italy  at  Salernum, 
and  in  Bologna,  where  Hugo  of  Lucca  flourished  during  the  first  half 
of  the  thirteenth  century,  and  was  followed  by  William  of  Salicet. 
We  have  no  writings  from  Hugo,  but  the  Cyrurgia  of  William  remains 
to  us.  The  first  edition  of  the  original  Latin  was  published  at  Placentia 
in  1476,  and  this,  with  other  editions,  including  French  translations 
(Lyons,  1492,  and  Paris,  1507)  and  an  Italian  translation  published  at 
Milan  in  1504,  is  in  the  Army  Medical  Library  at  Washington. 

William  of  Salicet  was  the  most  celebrated  .surgeon  of  his  century  ; 
he  M'as  an  educated  physician,  who  gives  some  of  his  own  observations 
and  his  own  conclusions,  hardly  citing  previous  authors,  although  it  is 
evident  that  he  was  familiar  with  the  works  of  Avicenna  and  of  Galen. 
It  is  a  pity  that  the  Ci/riirf/ia  has  never  been  translated  into  English. 

The  next  noted  surgeon  of  this  period  is  Lanfranc  of  Milan,  a  j^upil 
of  William  of  Salicet,  to  whom  he  refers  as  his  "master  of  goodly 
memory."  Lanfranc  also  received  a  university  education,  and  was  a 
physician  as  well  as  a  surgeon.  Political  troubles  having  caused  his 
banishment  from  Milan,  he  went  first  to  Lyons,  where  he  wrote  an 
epitome  of  surgery,  and  finally  in  1295  to  Paris,  where  he  gave,  at 
the  School  of  Medicine,  a  course  of  lectures  which  were  probably  em- 
bodied in  his  great  Surgery,  which  he  completed  in  1296.  He  was  thus 
the  introducer  of  the  new  Italian  ideas  into  France.  His  large  work 
was  first  published  at  Venice  in  1490  under  the  title  Pracfica  <juce  dis- 
cifur  a)-s  complda  totiu^  Chirurgi(r."  In  the  same  year  a  French  trans- 
lation by  Guillaume  Yvoire  was  published  at  Lyons,  and  of  this  there  is 
a  copy  in  the  Bibliotheque  Nationale  at  Paris. 

After  Lanfranc  came  Henri  de  Mondcville,  a  native  of  Normandy, 
of  whose  early  life  nothing  is  known  except  that  he  studied  at  Mont- 
pellier,  and  at  Paris  under  Jean  Pitard,  who  will  be  referred  to  hereafter, 
and  that  he  was  one  of  the  four  surgeons  of  the  court  of  Philip  the  Fair 
prior  to  1301.  In  1306,  at  the  request,  as  he  says,  of  Bernard  de  Gordon, 
a  distinguished  professor  of  Montpellier,  he  began  to  ^yrite,  and  to  read 
to  his  numerous  pupils,  a  systematic  treatise  on  surger>',  which  he  did 
not  complete,  although  he  lived  until  about  1318.  This  treatise,  of 
which  several  manuscripts  exist,  was  finally  edited  and  printed  by  Dr. 
Julius  Leopold  Pagel  of  Berlin  in  1892,  forming  an  octavo  volume  of 
660  pages  having  the  title  of  Die  Chinoyir  (h\<^  Heinrich  von  Mondeville 
{Hennondaville),  etc.,  and  has  been  translated  into  French  and  published 
in  1893  by  Professor  Nicaise  of  the  Faculty  of  Medicine  of  Paris.  His 
practice  is  much  the  same  as  that  of  Lanfranc,  and  of  his  successor,  Guy 
de  Chauliac,  who  often  quotes  him.  He  describes  the  method  of  ligating 
a  wounded  artery,  recommending  a  peculiar  kind  of  slipknot,  but  says 
nothing  of  ligating  the  vessel  in  amputations,  and  refers  to  the  use  of  the 
ansesthetic  sponge  described  by  Guy. 

Here  may  also  be  mentioned  the  Surgery  of  Master  Jean  Yperman, 
a  native  of  Flanders,  who  was  born  in  the  latter  part  of  the  thirteenth 
century  and  studied  under  Lanfranc  in  Paris.  The  manuscript  of  his 
book,  dated  1351,  Ayas  first  described,  and  in  part  published,  by  Dr. 
Carolus  in  the  Annales  de  la  Sociefe  de  Medecine  de  Gand  (vol.  xxxii. 


THE  HISTORY  ASD  LITERATURE  OF  SVRGERY.  41 

1854) ;  also  jniblished  separately  as  a  re])rint.  He  refers  to  Roger  and 
Roland  and  the  Four  Masters,  and  frequently  to  Lanfranc,  beyond  \vh(ise 
teaehings  he  seldom  ventures  to  go,  although  he  does  give  some  cases  of 
his  own. 

The  great  French  surgical  author  of  the  fourteenth  century  was  Gui 
(or,  as  it  is  more  usually  given,  Guy)  de  Chauliac,  "  Guido  de  Chauliaco," 
born  aliout  1300  A.  D.  He  received  the  university  training  of  the  cler- 
ical profession  and  studied  medicine  at  Paris,  after  wliich  he  continued 
this  study  at  Montpellier  and  Bologna,  so  that  he  had  tlie  lienelit  of  the 
three  greatest  universities  of  that  time — Paris  being  especially  celebrated 
for  its  surgery  after  Lanfranc  had  reached  it ;  Montpellier  being  the 
centre  for  medicine  ;  and  Bologna  for  anatomy,  of  which  Bertrucius  was 
then  professor.  After  extensive  travels,  and  practice  in  different  places, 
including  Lyons  and  Montpellier,  he  ^\•ent  to  Avignon  and  became  the 
physician  of  Pope  Clement  VI.  and  of  liis  successors.  Innocent  VI.  and 
Urban  V.  His  chief  literary  work  was  liis  Chinur/in,  written  at  Avi- 
gnon in  1363,  and  first  published  at  Lyons  by  Nicholas  Panis  in  1478. 

The  "  Great  Surgery "  begins  with  a  special  introductory  chapter, 
the  chapilrc  singuUer.  He  says :  "  Up  to  the  time  of  Avicenna  all 
writers  were  both  physicians  and  surgeons  (/.  e.  well-educated  men),  but 
since  that  time,  either  because  of  the  fastidiousness  or  the  excessive 
occupation  of  the  clerics,  surgery  has  become  a  separate  branch  and  has 
fallen  into  the  hands  of  the  mechanics. 

"  The  sects  which  have  existed  in  my  time  among  the  operators  of 
this  art,  besides  the  two  general  ones  of  the  Logicians  and  the  Empirics, 
have  l)een  five. 

"  The  first  was  the  school  of  Roger,  Roland,  and  the  Four  Masters, 
who  treat  all  wounds  and  abscesses  alike  with  cataplasms  and  poultices, 
on  the  ground  of  the  fifth  aphorism,  '  Lax  things  are  good,  and  crude 
bad.' 

"  The  second  was  the  school  of  Bruno  and  Theodoric,  which  treated 
all  wounds  alike  with  wine,  basing  their  practice  exclusively  upon  the 
maxim, '  The  dry  is  nearest  to  that  which  is  sound,  and  the  moist  to  that 
which  is  not  sound.' 

"  The  third  sect  was  that  of  William  of  Salicet  and  of  Lanfranc,  who 
wished  to  pursue  the  middle  course,  covering  and  dressing  all  wounds 
with  ointments  and  soft  plasters,  founding  this  practice  on  the  fourteenth 
maxim  of  the  Therapeutics — that  curation  has  one  sole  method  ;  tliat  the 
treatment  should  be  gentle  and  without  pain. 

"  The  fourth  sect  is  composed  of  all  the  military  men,  or  German 
chevaliers  and  others  following  the  army,  who,  with  conjurations  and 
potions,  oil,  wool,  and  cabbage-leaves,  dress  all  wounds,  basing  their 
practice  on  the  maxim  that  God  has  given  his  virtue  to  herbs  and  to 
stones. 

"  The  fifth  sect  is  of  women  and  of  many  fools,  who  refer  the  sick  of 
all  diseases  to  the  saints  solely,  saying,  '  Le  Seigneur  me  I'a  donnee  ainsi 
qu'il  luy  a  plfl ;  le  Seigneur  me  I'ostera  quand  il  luy  plaira ;  le  noni  du 
Seigneur  soit  benit.     Amen.'  " 

It  will  be  seen  that  Guy  is  quite  trenchant  in  his  summaries  and  crit- 
icisms, which,  however,  appear  to  be  on  tlie  whole  fair  and  justifialile. 

The  teachings  of  Guy  were  the  chief  authority  in  surgical  matters 


42  THE  HISTORY  AXD   LITERATURE  OE  SURGERY. 

for  over  two  litiiulri'd  years,  iuul  wcri'  tl:i'  basis  df  iHiiiicrous  abstracts, 
odinpemls,  and  commentaries.  He  contributed  little  that  was  orij^inal, 
although  he  gives  some  of  his  own  observations.  Follin  remarks  that  a 
sort  of  canulated  sound,  the  dressing  of  ulc^ers  with  sheet  lead,  and  some 
jM'culiarly-shajx'd  cauteries  are  his  chief  inventions  ;  l)ut  his  book  is  one 
of  the  monuments  of  surgical   literature. 

The  tSermo  ■■^cjitiiiiiis  dc  cyruryla  et  dc  dn'orafionc  of  Nicholas  Faleu- 
tiiis,  of  which  the  Washington  Library  has  an  edition  printed  at  Florence 
in  1507,  is  a  huge  folio  volume  compiled  from  the  works  of  Arab  writers, 
with  references  to  Roger  and  Roland,  but  not  to  Guy  de  Chauliac,  so  far 
as  I  have  found.  His  formula  of  words  is  "  Dixit  Haly,"  or  "  Avicen," 
or  "Albucasis,"  witliout  attempt  at  conuneiit. 

In  the  days  of  J^anfranc  and  (tuv  de  Chauliac  surgery  in  AVestcrn 
Europe  was  distinct  from  medicine,  and  was  looked  upon  as  a  trade  or 
handicraft  degrading  to  and  unworthy  of  physicians,  who  claimed  to 
belong  to  the  nobility.  The  physicians  \vere  of  the  priestly  class  and 
abhorred  the  shedding  of  blood,  and  their  traditions  were  adhered  to  long 
after  medical  teaching  in  the  universities  had  passed  into  the  hands  of 
laymen.  The  barl)erswerc  the  ordinary  surgical  operators,  and  the  reason 
for  this  is  given  by  Dr.  Gardner '  as  follows :  "  The  monks,  as  all  the 
Avorld  knows,  recpxired  to  have  their  heads  regularly  shaved,  but  it  is  not 
by  any  means  so  well  known  that  they  had  to  be  bled  at  stated  ]icriods. 
3Iinu(u>i  ed  was  the  form  of  words  descriptive  of  one  who  had  undergone 
the  operation,  the  meaning  being  that  he  had  been  minntus  xidu/uine — 
i.  e.  deprived  of  blood.  In  the  monastery  of  St.  Victor  at  Paris  there 
was  an  order  which  prescribed  such  minution  five  times  a  year  :  '  Prima, 
est  Scptembri ;  secunda,  ante  Adventum ;  tertia,  ante  Quadrigesimum ; 
quarta,  post  Pascha ;  quinta,  post  Pentacosta.'  The  monks,  therefore, 
required  to  have  about  them  those  mIio  could  lioth  shave  and  bleed,  and 
it  was  very  natural  that  they  should  prefer  that  one  antl  the  smne  person 
should  ])erform  both  these  operations." 

In  France,  however,  at  an  early  date  there  were  a  few  persons  whose 
business  was  the  performance  of  surgical  operations,  and  who  were  not 
ordinary  barbers,  although  they  may  have  served  an  ajiprenticeship  as 
such.  The  Cor]ioration  of  Barbt'rs  in  the  middle  of  the  thirteenth  cen- 
tury was  divided  into  two  classes — the  ordinary  or  lay  barbers,  afterward 
known  as  "barber  surgeons"  or  "surgeons  of  the  short  robe,"  and  the 
"  clerk  barbers  "  or  "  surgeon  barbers,"  "  the  surgeons  of  St.  Come,"  or 
"  surgeons  of  the  long  robe  ; "  and  these  last  sought  to  be  independent 
of  the  ordinary  barbers,  to  monopolize  surgical  operations,  and  to  raise 
their  association  from  the  position  of  a  trade  guild  to  that  of  a  profes- 
sional oryanization.  The  Guild  of  the  Snry-eon  Barbers  was  organized  in 
1268  by  an  order  of  the  provost  of  Paris,  selecting  six  surgeons  who 
were  to  examine  and  license  those  who  wished  to  practise,  more  esjiecially 
the  barbers.  Possibly  one  of  these  masters  was  the  celebrated  Jean  Pitard, 
but  if  so  he  must  have  been  very  young,  for  he  was  still  living  in  1326. 
In  1311,  Pitard  obtained  a  decree  from  King  Phili])  the  Fair,  in  which, 
after  reciting  that  all  sorts  of  quacks  are  infesting  the  city,  it  is  ordered 
that  "  no  male  or  female  shall  practise  surgery  in  Paris  who  has  not  been 

^  Gardner  (John) :  Sketch  of  the  Early  Ilislonj  of  the  Medical  Profession  in  Edinburgh, 
Edinb.,  1864,  p.  6. 


THE  HISTORY  AND  LITERATURE  OF  SURGERY.  43 

exaniinod  liy  our  sworn  surgeons  of  Paris  named  and  called  togetlior  for 
tliat  purpose  by  Jean  Pitard,  our  sworn  surgeon  of  the  C'liiitelet,  or  his 
successors." 

It  was  evidently  impossible  to  enforce  this  order,  for  it  was  repeated 
in  1352,  and  again  in  1364,  with  penalties  of  Hues  on  the  erring  barbers, 
half  of  the  fines  to  go  to  the  surgeons'  guild,  the  Brotherhood  of  8t.  Come. 
The  organization  of  tiiis  brotherhood  was  by  no  means  pleasing  to  the 
medical  faculty,  the  memljcrs  of  which  desired  to  retain  control  of  all 
branches  of  the  art,  and  discredited  surgery  as  a  mere  mechanical  handi- 
craft only  to  be  exercised  under  the  direction  of  a  physician,  whose  dig- 
nity forbade  him  to  soil  his  hands.  The  statutes  of  the  facidty  in  1360 
recpiirc  the  candidates  to  make  oath  that  they  will  not  practise  surgeiy 
in  the  sense  of  performing  operations  or' making  applications  by  the 
hands,  including  the  treatment  of  five  classes  of  affections — viz.  wounds, 
ulcers,  fractures,  dislocations,  and  tumors. 

The  lay  barbers  were  employed  by  the  physicians,  and  also  sometimes 
as  assistants  by  the  surgeons,  and  at  last,  in  1372,  the  barber  of  the  king, 
being  the  master  of  the  guild  of  barbers  by  virtue  of  his  position,  induced 
Charles  V.  to  issue  an  edict  which  permitted  them  to  treat  wounds 'and 
sores  and  forbade  the  surgeons  to  interfere  \vith  them.  The  relative 
standing  in  the  eyes  of  the  public  of  the  three  kinds  of  practitioners — 
viz.  the  physicians,  the  surgeons,  and  the  barbers — may  be  inferred  from 
an  order  issued  during  an  epidemic  of  the  pest  in  1383,  which  directed 
that  there  shall  be  selected  to  visit  the  sick  four  physicians,  two  sur- 
geons, and  six  barbers,  and  the  fees  of  tii(^  doctors  shall  be  three  hundred 
livres,  of  the  surgeons  one  lunidred  and  twenty  livres,  and  of  the  barbers 
eighty  livres. 

The  so-called  College  of  Surgeons  of  Paris  was  not  in  the  least  a 
surgical  school  or  an  association  for  mutual  discussion  and  improvement : 
it  was  })urely  a  trade  guild,  and  the  students  were  simply  apprentices  to 
the  master  surgeons,  becoming,  after  1370,  bachelors,  licentiates,  and 
finally  masters.  The  surgeons  had  a  free  dispensary,  where  they  treated 
the  poor  once  a  week,  and  perhaps  the  apprentices  saw  there  something 
of  the  jtractice  of  other  masters  besides  their  own. 

The  medical  faculty,  thinking  that  its  rights,  privileges,  and  monopoly 
of  treating  the  sick  were  being  encroached  upon  by  the  surgeons, 
encouraged  the  barbers  in  their  controversies,  and  as  one  means  of 
doing  this  undertook  to  teach  them  anatomy.  As  the  barbers  did  not 
understand  Latin,  which  was  the  only  dignified  and  proper  language  to 
be  used  in  teaching  in  those  days,  a  compromise  was  necessary,  and  this 
was  effected  partly  by  the  use  of  a  sort  of  dog-Latin,  of  French  words 
with  I^atin  terminations,  and  partly  by  reading  Guy  de  Chauliac  in  Ijatin, 
but  with  comments  in  French,  wiiile  the  assistant  barber  made  tlu' 
incisions  in  the  cadaver  and  pointed  out  the  ])arts  as  tiie  reader  named 
them.  In  1505  the  bai'bers  came  moi-e  formally  under  the  protection 
and  jurisdiction  of  the  faculty,  and  assumed  the  name  of  the  Guild  of 
the  Barber  Surgeons,  and  a  few  years  later  the  surgeons  of  the  long 
robe,  having  opposed  this  movement  with  very  little  success,  and  luu'ing 
failed  to  become  a  separate  faculty  in  the  university,  submitted  to  also 
receive  instructions  from  the  physicians.  Almost  all  the  medical  officers 
attached  to  the  French  armies  came   from   tlie  Corporation  of  Barber 


44  THE  HISTORY  AND   LITERATURE  OF  SURGERY. 

Sui'creons,  and  finally  <mc  of  tiieni,  Ambrose  Par^,  acqnired  so  much 
reputation  and  influence  as  to  considerably  increase  the  respectability 
and  standing  of  the  guild.  As  a  sample  of  surgical  associations  in  the 
provinces  we  may  take  the  surgeons  of  Bordeaux,  who  in  1519  formed 
a  society  composed  of  bcjaunes  (yellow  beaks  or  young  birds — /.  e. 
aspirants)  and  companions.  They  had  a  password  and  special  secrets ; 
instruction  was  given  in  the  winter  at  5  A.  M.  in  the  form  of  commen- 
taries on  Guy  de  C'hauliac,  and  in  the  course  of  one  hundred  and  sixty- 
nine  years  five  bodies  were  dissected.* 

There  is  little  of  importance  in  the  history  of  surgery  during  the 
next  hundred  years  after  the  death  of  Guy  de  Chauliac.  Peter  of 
Argelata,  lecturer  on  surgery  at  Bologna  about  the  beginning  of  the 
fifteenth  century  and  dying  in  1423,  was  the  principal  surgeon  of  his 
time.  His  six  books  on  surgery,  edited  by  Maretus,  first  pul)lished  at 
Venice  in  1480,  are  largely  derived  from  Paulus  and  Guy.  He  was  an 
operator  as  well  as  a  theoretical  teacher,  jierformed  lithotomy  and  her- 
niotomy, embalmed  Pope  Alexander  VI.,  practised  craniotomy  of  the 
f'wtus  in  difficult  labors,  etc.  A  copy  of  his  books  was  annotated  on 
the  margins  by  Marcellus  Cumanus,  a  surgeon  in  the  Venetian  army 
in  1495,  and  these  observations  were  finally  published  by  Velschius 
(G.  H.)  in  his  Sylloge  Vurationum  (Aug.  Vindel.,  I(j68).  Cumanus 
found  nothing  in  Argelata  about  the  treatment  of  gunshot  wounds,  and 
he  noted  a  formula  for  this  purpose  consisting  of  a  mixture  of  oil  of 
roses,  galbanum,  and  asaf'oetida,  to  be  applied  hot. 

Gunj)o\\-der  was  used  in  warfare  at  least  as  early  as  1338  ;  the  English 
employed  it  at  the  battle  of  Crecy  in  134(),  l)ut  it  was  a  longtime  before 
any  surgeon  published  an  account  of  gunshot  injuries  and  their  treatment. 
The  first  Italian  surgeon  to  do  this  was  John  de  Vigo  (1460-152-),  sur- 
geon of  Pope  Julius  II.  in  1503,  whose  Pracfica  in  Arte  Vhintrgica 
Copiosa  was  first  published  at  Rome  in  1514.  This  book  had  twenty- 
one  editions  in  thirty  years,  and  was  translated  into  Italian,  French, 
English,  Spanish,  Dutch,  German,  and  Portuguese.  The  great  success 
of  the  book  was  due  partly  to  the  fact  that  it  was  the  first  complete 
system  of  surgery  issued  after  that  of  Guy  de  Chauliac,  partly  to  the 
fact  that  it  contained  an  account  of  gunshot  wounds  and  a  section  on  the 
new  disease,  syjihilis,  and  also,  probably,  to  a  considerable  degree,  because 
it  was  a  book  which  specially  suited  a  practitioner  who  knew  nothing  of 
anatomy  and  feared  or  disliked  to  make  use  of  the  knife.  It  is  essen- 
tially a  surgery  of  plasters,  ointments,  and  embrocations,  and  the  name 
of  the  author  is  best  known  to-day  in  connection  with  the  "  emplastrum 
de  Vigo." 

The  part  relating  to  gunshot  wounds  is  brief.  He  says  they  are  con- 
tused and  burned,  and  therefoi-e  need  moist  applications,  but  that  they 
are  also  jioisoned  by  the  powder,  and  therefore  need  desiccation  ;  hence 
thev  are  hard  to  cure.  They  are  to  be  cauterized  with  the  actual  cautery 
or  with  boiling  oil  of  elder,  "  for  cauterization  kej^eth  the  wounde  from 
putrefyinge." 

His  chapter  on  syphilis  begins  as  follows  (I  use  the  English  transla- 
tion of  1543):  "In  the  yeare  of  our  Lord  1494,  in  the  moneth  of 
December,  when  Charles  the  Frenche  kynge  toke  hys  jorney  into  the 

'  Sous  (G.) :  Bnnkaux  medicale,  1877,  p.  49. 


THE  HISTORY  AND  LITERATURE  OF  SURGERY.  45 

partes  of  Ytaly  to  recover  the  kyiiiidome  ot'  Xaples,  tliere  appeared 
a  certaiue  dysease  tliroughout  al  Ytaly  of  unknowen  nature,  whicli 
sondre  nations  hath  called  by  sondry  names.  The  French  men  call 
it  the  dysease  of  Naples,  because  the  souldyours  brought  it  from  thence 
into  France.     The  Neapolitanes  call  it  the  Frenche  dysease." 

Controversies  as  to  whether  syphilis  existed  prior  to  the  fifteenth  cen- 
tury have  been  many,  and  the  literature  on  the  subject  is  voluminous ; 
but  no  positive  and  convincing  proofs  of  such  existence  have  yet  been 
found,  although  it  is  probable  that  it  did  occur  before  that  time.  One 
of  the  theories  of  its  origin,  advanced  first  by  Leonard  Schmaus  in  the 
preface  to  his  little  pampidet,  Lucubratiuxcula  dc  morbo  ynJllco  et  cam 
(JKS  noritcr  rrpcrta  cum  li(/iio  iiulico  (sm.  4°,  Aug.  Vindel.,  lolS),  is  that 
it  was  brought  from  the  AVest  Indies  by  the  sailors  who  returned  with 
Columbus  after  his  first  voyage,  and  attempts  have  been  made  to  furnish 
positive  evidence  of  this  from  human  bones  showing  evidence  of  disease, 
and  antedating  the  Columbian  discovery  ;  but  none  of  these  have  been 
convincing  to  skilled  pathologists.  Schmaus  says  in  his  preface  that  he 
learned  of  its  American  origin  from  merchants  and  sea-captains ;  but  it 
is  probable  that  this  idea  was  first  suggested  by  the  use  of  guaiacum  in 
this  disease.  Guaiacum  came  from  America,  and  it  was  a  common  idea 
that  the  bane  and  the  antidote  belonged  together  and  were  to  be  found 
in  the  simie  vicinity.  It  is  certain  that  the  disease  existed  in  America 
soon  after  the  second  voyage  of  Columbus. 

After  John  de  Vigo  came  Alexander  Benedictus  (14o  ?-l  o25),  who  was 
professor  of  anatomy  at  Padua,  an  army  surgeon,  and  who  operated  for 
hernia  and  calculus.  He  is  the  author  of  treatises  on  anatomy  and  on 
the  pest,  and  of  De  omnium  a  verfiee  ad  plantam  morborum  signis, 
etc.  (Venice,  1535;  Basil,  1594),  which  contains  his  surgical  recom- 
mendations. 

Jacobus  Berengarius  Carpensis  (147?-1560),  professor  in  Bologna,  was 
the  author  of  a  celebrated  treatise,  Tracfatus  de  fractura  cah'oriae  seio 
cranei  (Bologna,  1518,  quarto),  of  which  a  number  of  editions  were 
jiublished.  This  also  contiiins  a  few  remarks  on  the  ti-eatment  of  gun- 
sliot  wounds,  which  he  supposed  to  be  burned  or  more  or  less  poisoned. 
He  acquired  a  great  fortune  at  Rome  by  his  treatment  of  syphilis  with 
mercurial  inunctions,  of  which  he  is  reported  to  have  been  the  inventor. 

Alfonso  Ferrius  (1500- ?)  of  Naples,  the  physician  of  Pope  Paul 
III.,  wrote  Dc  Sclopetorum  sive  Archibusorum  Vulneribus,  librl  tres 
(Rome,  1552,  quarto),  in  which  he  maintains  that  gunshot  wounds  are 
poisoned  and  must  be  treated  accordingly. 

Bartholomieus  Maggius  (1516-62)  of  Bologna  wrote  De  Vulnerwn 
Hclopctorum  et  bombardonoii  globidis  Ubitorum,  etc.  (Bologna,  1552, 
quarto),  of  which  there  Mere  numerous  later  editions. 

Leonardo  Botallo  (1530- ?)  wrote  De  Ciirandis  ^'ulneribus  Sclope- 
torum (Lyons,  1 580,  octavo),  in  which  he  opposed  the  views  of  De  Vigo 
and  Ferrius  as  to  the  poisoned  condition  of  gunshot  wounds. 

Joh.  F.  Rota,  who  lived  in  the  middle  of  the  sixteenth  century,  wrote 
De  bel/iconim  toniientorum  vidnerum  uatura  et  cundione  liber  (Bologna, 
1555,  quarto). 

One  of  the  wisest  of  the  Italian  surgeons  of  this  period  appears  to 
have  been  Michael  Angelo   Blondus  (Biondi)  (1497-15?)  whose   little 


40  THE  lUSTonV   AMI    I.ITEHATrUE  OF  KUROERY. 

treali.su  J>c  jMtrtibiia  irtn  srcti-s,  tir.st  j)Liblirihud  in  U'A'2,  and  wiiich  is 
contained  in  the  Gesner  Collection  and  also  in  Utfenbach's  Thesaurus, 
strongly  urges  the  use  of  simple  wat(>r  and  Avetted  lint  in  the  dressing 
of  Wduntls.  Nevertheless,  he  was  a  ])artisan  of  the  aneients,  and  two 
of  iiis  sayings  have  l)econie  historical  as  illustrating  the  university  sjjirit 
of  tile  age— viz.  "  It  is  more  honorable  to  err  with  (Jalen  and  Avicenna 
tiian  to  at'cjuire  glory  with  others  ;"  and,  "  It  is  better  to  die  l)y  a  regular 
j)hysieian  than  to  live  by  a  quack." 

One  of  the  most  celebrated  Italian  surgeons  of  the  sixteenth  century 
was  Gaspar  Tagliacozzi,  l)etter  known  as  Tagliaeotius  (.1546-09),  who 
was  professor  of  anatomy  and  surgery  in  tiic  University  of  Bologna,  and 
wrote  tlie  hrst  special  ti'eatise  on  ])lastie  surgery,  and  more  particularly 
on  the  o])eratiou  of  rhinoplasty,  with  which  his  name  is  especiall)'  asso- 
ciated. The  title  of  his  book  is  De  Curtorum  Chirurgia  per  insiiionem, 
libri  duo,  of  which  two  editions  wei'e  published  at  Venice  in  1597.  One 
of  these,  a  large  folio  jiulilished  by  Ga.sjiar  Bindonus,  is  celebrated  for 
the  beauty  of  its  plates,-  the  quality  of  the  paper,  and  its  typography, 
being  a  splendid  specimen  of  book-making ;  the  other  edition  of  the 
same  date  and  place,  jiublished  by  Robert  Meiettus,  is  also  a  folio,  but 
a  much  poorer  specimen  of  the  printer's  and  engraver's  art.  There  is 
also  a  small  octavo  edition  of  Frankfort  (1598),  and  one  was  published 
in  Berlin  so  late  as  18.'U.  He  does  not  name  the  iierson  from  whom  he 
had  learned  his  method,  but  it  was  probably  from  some  one  of  the  Inc-isors 
of  his  day  who  had  ac([uired  his  knowledge  from  a  jnipil  of  one  of  the 
Sicilian  Brancas,  who  were  celebrated  for  operations  of  this  kind  in  the 
middle  of  the  fifteenth  century.  The  elder  Branca  took  his  flaps  for  a 
new  nose  from  the  skin  of  the  face,  being  the  Indian  method ;  his  son 
made  use  of  the  skin  of  the  arm,  and  extended  the  method  to  repair  of 
nuitilated  lips  and  ears,  as  we  are  informed  by  Bartholomeo  Fazia. 

The  first  notice  of  Tagliacozzi's  method  is  givi'n  by  H.  Mercurialis 
in  his  Dc  decorafione  liber  (4°,  Venet.,  1585,  fol.  23).  Two  of  his 
pupils  describe  the  methods  and  the  results  obtained,  and  acquired 
repute  by  their  performance  of  the  operation — viz.  Thomas  Fienus  of 
Antwerp,  and  Jo.  Bapt.  Cortesius,  who  succeeded  Tagliacozzi  as  pro- 
fessor at  Bologna  ;  but  the  practice  fell  into  disuse  among  surgeons, 
and  little  was  heard  of  it  until  the  beginning  of  the  nineteenth  century. 
A  curious  use  of  plastic  surgery  is  mentioned  by  Fortunatus  Licetus — 
viz.  the  making  of  double  mon.sters  for  show  purposes  by  grafting  two 
boys  together  by  the  back,  nates,  or  arms,  upon  which  he  says  :  "  Aver- 
runcct  Deus  e  severe  puniant  principes  tales  sicophantes."  Victor  Hugo 
refers  to  the  work  of  these  "  monster-makers"  in  his  L' Homme  (jni  rit. 

Marianus  Sanctus  Barolitanus  (1490-154?),  a  native  of  Naples  and 
a  special  pupil  of  John  de  Vigo,  wrote  a  treatise  entitled  Compendium 
in  Chyrurgia  Utilissimum  Volentibuti  ipsas  exercere,  which  was  first  pub- 
lished at  Rome  in  1516,  and  subsequently  appeared  in  connection  with 
the  works  of  De  Vigo.  It  is  also  in  the  Gesner  Collection  of  1555. 
Neither  Haller  nor  Malgaigne  knew  the  date  of  the  first  edition,  which 
is  jirobablv  rare.  The  copy  in  the  Washington  Libi'ai'v  is  a  small  quarto 
of  fifty  leaves,  unnuml)ered  and  unpaged,  and  is  a  fine  specimen  of  black- 
letter  printing.  It  contains  three  small  rude  figures  of  cauterizing  irons, 
and  the  last  nine  pages  are  occupied  with  his  Traetatus  de  Capite.     Mari- 


THE  HISTORY  ASD  LITERATURE  OF  SURGERY.  47 

anus  Sanctus  is  best  known  by  his  treatise  Dc  LaphJc  c.v  resica  per  iiicis- 
ionem  e.vtrahenda,  in  which  was,  tor  the  tirst  time,  pulilished  the  method 
of  John  de  Romanes  for  lithotomy  with  a  grooved  staff,  upon  which  an 
incision  was  made  into  the  membranous  portion  of  the  urethra,  after  Mhich 
instruments  were  introduced  to  dihite  or  rupture  tlie  prostatic  portion. 
This  is  ivnown  as  "  the  metliod  ^vith  the  great  apparatus,"  from  the  num- 
ber of  instruments  required,  and  also  as  the  "  Marian  operation,"  from 
the  name  of  the  person  ^\•\\o  tirst  pul)lished  the  description.  The  first 
edition  of  this  treatise  appeared  at  Venice  in  1535.  It  is  contained  in 
the  Gesner  Collection  of  1555  and  in  Uflenbach's  Thesaurus  of  1610. 

The  "  Gesner  Collection,"  also  known  as  the  "  Geneva  Collection," 
is  a  beautifully  printed  folio  with  the  title  Chiruryin.  De  chirurf/ia 
licriptoreti  optiini  <jui<jue  reteret^  et  irceHtiorex,  etc.  (Tiguri,  1555).  It  was 
edited  by  Conrad  Gesner,  and  contains  the  principal  surgical  works  of 
Tagaultius,  Hollerius,  Marianus  Sanctus,  Bologninus,  Blondus,  Maggius, 
Ferrius,  liangius,  and  others,  forming  a  valuable  book  of  reference. 

The  first  collections  of  the  works  of  different  writers  on  surgery  were 
published  at  Venice,  the  first  being  a  small  volume  issued  in  1490,  and 
again  in  1497,  containing  the  Chirnrgia  parva  of  Guy,  the  Surgery  of 
Albucasis,  and  the  commentary  of  Bertapaglia  on  Avicenna.  A  nuich 
more  complete  collection  is  the  Venice  folio  of  1498,  which  contains  the 
■works  of  Guy  de  Chauliac,  Brunus,  Theodoricus,  Lanfranc,  Roger,  and 
Bertapaglia.  Of  this  the  Venice  editions  of  1499  and  1519  are  in  the 
Washington  Library;  also  the  edition  of  1546,  which  is  the  best  and 
contains  also  the  treatises  of  Roland  and  of  William  of  Salicet. 

From  very  early  times  there  were  to  be  found  througliout  Western 
Europe — in  France,  in  Italy,  in  Germany,  and  in  England — a  certain 
number  of  surgical  practitioners  known  to  the  writers  of  that  time  as 
"  The  Cutters  "  or  "  Incisors."  Those  who  operated  for  lithotomy,  her- 
nia, etc.  were  of  the  first  class.  They  travelled  about  from  place  to 
place,  and  maintained  more  or  less  secrecy  as  to  their  methods,  which 
were  held  as  a  special  family  property,  being  handed  down  from  father 
to  son.  Among  these  may  be  mentioned  tiie  two  Brancas,  to  whom 
reference  has  been  made  in   speaking  of  Tagliacozzi. 

Another  group  of  these  travelling  operators  was  known  under  the 
name  of  Xorsini.  These  devoted  themselves  j)rincipally  to  operations 
for  hernia  and  to  lithotomy.  Fabrice  d'A(iuapendente  mentions  Horace 
of  Norsia  as  a  skilled  operator  in  hernia.  Sylvaticus  in  1601  complains 
that  tile  operation  of  lithotomy  was  abandoned  to  ignorant  persons,  like 
the  Xorsini.  In  1633,  Cortesi  writes  that  at  Messina  he  had  seen  Ulysses 
of  Norsia  treat  hernia  by  the  application  of  caustic,  followed  by  incision 
of  the  eschar;  and  still  later,  in  1672,  Bernardino  Genga  says  that  the 
Norsini  had  some  experience  in  the  treatment  of  diseases  of  the  urinary 
organs. 

To  this  class  of  Cutters  belongs  probably  the  unkuo\\'n  surgeon  men- 
tioned by  Senarega,  who  in  his  history  of  Genoa  says  that  there  died 
there  in  1510  a  surgeon  very  skilled  in  removing  calculi.  He  intro- 
duced into  the  penis  an  iron  rod,  \\hich  entered  tiie  body  until  it  met 
the  stone  which  he  was  seeking,  and  wliich  he  then  removed  by  a  perineal 
incision.  It  is  supposed  by  some  that  tliis  unknown  Genoese  taught 
his  method  to  John  de  Romanes  of  Cremona,  who  is  ordinarilv  credited 


48  THE  HISTORY  AND  LITERATURE  OF  SURGERY. 

witli  the  iuvontion  of  tlie  fjrodvetl  stniJ'  for  lithotomy,  and  who  taught 
his  metliod  to  his  assistant,  Marianus  Sanctus. 

The  most  famous  of  the  Incisors  was  Pierre  Franco,  a  native  of 
Provence,  horn  ahout  1500,  who  operated  in  Provence,  Burgundy,  and 
Switzerland,  finally  settling  in  Lausanne  for  a  considerahle  period,  and 
in  1501  living  at  Orenge.  His  I'dit  trdite  contciKiiit  line  den  particx 
principaUes  de  chiruiyie  laquelle  lea  chirurgienn  hernih-es  exercent  was 
jjublished  at  Lyons  in  1556.  In  this  he  describes  and  figures  the 
"  Algalie "  sound  for  detectmg  stone  in  tlie  bladder ;  says  that  the 
calculus  is  sometimes  encysted  so  that  it  cannot  be  felt  by  the  sound  ; 
describes  the  old  operation  of  "cutting  on  the  gripe,"  which  he  says  he 
formerly  used;  the  operation  with  a  grooved  sound  and  gorget,  of  both 
of  which  he  gives  figures,  as  also  of  forceps  for  crushing  the  stone  if  it 
is  large ;  and  concludes  that  if  the  stone  does  not  present  itself  when  the 
incision  is  made,  it  is  best  to  wait  a  day  or  two  before  attcm])ting  to 
remove  it.  He  describes  a  case  in  a  child  ten  years  old  in  which,  being 
unable  to  extract  the  stone  through  the  perineal  incision,  he  performed 
the  suprapubic  operation,  removed  the  stone,  which  was  the  size  of  an 
egg,  and  the  patient  recovered.  This  is  the  first  recorded  case  of  the 
high  ojjeration  for  stone.  He  says,  however,  that  he  does  not  advnse 
this  in  ordinary  cases.  In  his  description  of  amputation  he  does  not 
mention  the  ligature,  but  advises  the  actual  cautery,  and  gives  figures  of 
the  sickle-shaped  knife,  the  saw,  and  the  cautery-iron.  In  1561  he  pul)- 
lished  at  Lyons  his  Truite  dcs  hernicn  conk'nant  une  ample  declaration 
de  toutes  leiirs  esp^cc><  &  autres  e.rcellentes  parties  de  la  chirurgie,  assavoir 
de  la  pierre,  des  cataractes  des  yeux,  &  autres  maladies,  desquelles  comme 
la  cure  est  perilleuse,  aussi  est  elle  de  peu  d'hommes  bien  excrcee.  This  is 
a  small  octavo  of  16  preliminary  leaves,  554  pages,  and  1  leaf  of  errata. 
It  contains  all  the  matter  of  the  preceding  book,  and  much  more,  with 
figures  of  new  instruments,  and  is  really  a  small  manual  of  surgery. 
The  part  relating  to  lithotomy  remains  substantially  the  same.  Next  to 
the  works  of  Pare,  this  is  the  most  valuable  contribution  of  the  century 
to  surgical  literature. 

The  history  of  the  Colot  famil}'  is  curious  and  interesting,  but  is 
wrongly  given  by  most  of  the  biographers :  the  best  is  that  given  by 
Dr.  E.  "Turner  in  the  Gaz.  Hebd.  de  MM.  et  de  Chir.  (Paris,  1880,  xvii. 
2'  ser.  pp.  33,  49). 

The  story  that  a  certain  Germain  Colot,  a  French  surgeon,  learned 
the  details  of  the  methods  of  some  of  the  Incisors  about  1460,  and  then, 
returning  to  Paris,  operated  on  an  archer  who  had  been  condemned  to  be 
hung,  but  whose  sentence  was  changed  by  the  king  to  be  operated  on  by 
Coli>t,  is  probably  without  foundation.  The  original  account,  given  in 
the  Chronique  scandaleuse,  does  not  mention  the  name  of  the  operator, 
and  Malgaigne  says  that  there  is  not  even  a  presumption  that  there  ever 
was  a  surgeon  named  Germain  Colot. 

There  was,  however,  a  Laurent  Colot  or  Collot,  who  lived  at  Tresnel, 
near  Troyes,  in  the  middle  of  the  sixteenth  century,  and  who  learned 
the  method  of  John  de  Romanes — or  what  is  called  the  IMarian  opera- 
tion— from  an  itinerant  lithotomist  named  Octavien  da  Villa.  He  kept 
the  method  a  secret  and  had  great  success,  being  called  to  Paris  in  1556, 
and  was  appointed  lithotomist  of  the  Hotel  Dieu.     The  secret  and  the 


THE  HISTORY  AND  LITERATURE  OF  SURGERY.  49 

office  remaiiK'fl  in  the  family,  the  grandson  Piiilijjpe  (1593-1650)  lieing 
called  to  all  parts  of  Europe  to  operate.  His  son  Fran(,-ois  (1630-1706) 
wrote  an  aeeount  of  the  niethoil,  which  was  published  after  his  death 
under  the  title  Traitii  dc  rope  rat  ion  de  la  taillr,  etc.  (Paris,  1727).  In  it 
he  refers  to  the  above-mentioned  story  about  Germain  C'ohrt,  but  does 
not  give  his  name,  and  asserts  tiiat  the  operation  ])erformed  on  the  archer 
was  a  nephrotomy  and  not  a  lithotomy.  That  the  so-called  family  secret 
could  have  been  preserved  until  the  beginning  of  the  eighteenth  century, 
after  the  publication  of  the  method  by  Marianus  Sanctus  in  1535  and  by 
Franco  in  1556,  illustrates  tlie  education  of  the  surgeons  of  those  days. 
We  now  come  to  an  epoch-making  surgeon,  Ambrose  Pare  (1517-90), 
who  was  apprenticed  to  a  provincial  barl>er  when  he  was  about  nine 
years  old.  In  1532  he  came  to  Paris,  where  he  was  probably  again  ap- 
prenticed to  a  barber  surgeon  and  attended  the  lectures  of  the  doctor  of 
the  Faculty  of  Medicine  of  Paris,  whose  business  it  was  to  explain  to 
the  voung  Ijarber  surgeons  those  parts  of  the  surgery  of  Guy  de  Chauliac 
which  relate  to  tumors,  wounds,  and  ulcers.  Very  soon  after  his  arrival 
at  Paris  he  had  the  good  fortune  to  obtain  a  position  as  resident  a})pren- 
tice  and  dresser  in  the  great  hospital  of  the  Hotel  Dieu.  Here  he  had 
opportunities  for  dissections,  for  making  post-mortem  examinations,  and 
for  the  study  of  disease,  of  which  he  was  not  slow  to  avail  himself.  In 
his  preface  to  the  reader  he  says  :  "  You  must  know  that  for  the  space 
of  tliree  j-ears  I  have  lived  in  the  Hotel  Dieu  of  Paris,  where  I  had  the 
means  of  seeing  and  knowing  (in  consequence  of  the  great  variety  of 
diseases  brought  there)  all  which  can  be  of  alteraticm  and  disease  in  the 
human  body,  and  to  learn  from  an  infinite  number  of  dead  all  that  can 
be  said  of  anatomy." 

At  the  end  of  this  service,  when  he  was  but  nineteen  years  old,  he 
became  body-surgeon  to  Mareschal  Monte  Jan,  and  went  with  him  in  the 
army  which  Francis  I.  opposed  to  that  of  Charles  V.  in  the  invasion  of 
Provence  in  1536.  Gunshot  wounds  were  supposed  to  be  poisoned,  and 
the  recognized  means  of  destroying  the  venom  was  that  prescribed  by 
John  de  Vigo — namely,  cauterization  by  boiling  oil.  But  in  one  battle 
the  supply  of  oil  was  insufficient,  and  our  conscientious  youth  could  not 
sleep  that  night  for  thinking  of  the  horril)le  fate  that  was  in  store  for  the 
poor  fellows  who  had  not  been  cauterized,  (jreat  was  his  astonishment 
and  delight  the  next  day  on  finding  that  those  who  had  not  been  burnt 
were  much  more  comfortable  than  those  who  had  been  treated  sceundam 
artem,  and  that  recovery  was  prompter  and  more  certain  in  their  case. 
But,  while  Pare  had  the  sense  and  the  independence  to  refuse  to  give 
unnecessary  pain,  although  commanded  to  do  so  by  the  highest  surgical 
authority  of  his  day,  he  could  not  free  himself  from  the  notion  that  some 
special  treatment  was  recpiired  for  gunshot  wounds,  nor  accept  the  plain 
teaching  of  his  own  experience.  He  decided  that  the  best  thing  to  be 
done  was  to  use  a  secret  remedy  which- was  the  stock  in  trade  of  a  certain 
surgeon  in  Turin,  and  to  learn  the  composition  of  this  remedy  he  assidu- 
ously courted  the  good  graces  of  this  surgeon  for  over  two  vears  and  a 
half,  and  finally  obtained  the  se(>ret  for  a  round  price,  ])romising  not  to 
divulge  it.  It  was  an  oil  of  ])uppies,  not  much  different  from  lard— a 
simple  protecting  soothing  application.  No  sooner  had  Pare  learned  the 
secret  than  he  hastened  to  publish  it,  deliberately  breaking  his  promise 

Vol.  I.— t 


50  Tllf':  HISTORY  AXI)  LITERATURE  OF  SURGERY. 

on  the  crniind  tliat  siioli  nn  important  matter  should  not  be  one  man's 
priviletic 

The  areat  ini])rovem(iit  made  l)y  Pare  in  snrti^erv  was  the  use  of"  the 
ligature  to  close  bleeding  arteries  after  amputation  in  place  of  scaring 
them  with  red-hot  irons,  as  had  been  done  down  to  his  time. 

In  the  edition  of  his  works  published  in  15(34,  Dix  Hvreft  ck  Chlni/r/ic, 
he  first  describes  and  recommends  the  application  of  a  ligature  to  lilccd- 
ing  vessels  in  amputations,  and  abandons  the  use  of  the  cauteiy.  His 
account  is  as  follows:  After  alluding  to  the  j)assage  in  Galen  which 
states  that  "the  vessels  must  be  tied  toward  their  roots,  which  are  the 
liver  and  the  heart,  to  staunch  the  great  flow  of  blood,"  he  says :  "  But 
having  many  times  used  this  means  of  closing  the  veins  and  arteries  in 
recent  wounds  where  there  was  a  hemorrhage,  I  thought  it  might  also  be 
done  in  amputating  a  member.  Therefore,  having  conferred  with  Esti- 
ennc  de  la  Iviviere  and  Francois  Kasse,  both  surgeons  at  Paris"  [in 
later  editions  the  name  of  Rasse  is  struck  out  and  in  place  is  read  "  other 
sworn  surgeons  of  Paris  "],  "  we  agreed  that  we  would  make  the  trial 
upon  the  first  patient  which  offered,  although  we  would  have  the  cau- 
teries all  ready  to  use  if  the  ligature  failed."  A  few  days  afterward  the 
ligature  was  applied  with  success  in  a  case  of  amputation  of  the  leg. 

Pare  was  a  good  anatomist,  by  far  tlie  greatest  surgeon  of  his  time, 
the  confidential  friend  of  four  successive  kings,  and  is  said  to  have  been 
the  only  Protestant  in  I'aris  v.\w  was  spared  the  massacre  of  St.  Bar- 
tholomew, which  was  due  to  the  direct  action  of  the  king.  Malgaigne's 
argument  against  the  truth  of  this  story  cannot  outweigh  the  direct  state- 
ments of  Sully  and  of  Brantome. 

Catherine  de  Medici  one  day  asked  Pare  whether  he  hoped  to  be 
saved  in  the  next  world.  "  Yes,  certcs,  madame,"  said  he,  "  because  I 
do  what  I  can  to  be  a  brave  man  in  this  world,  and  because  the  mercifid 
God  understands  all  languages,  and  is  as  well  satisfied  with  a  French 
prayer  as  with  a  Latin  one." 

To  properly  appreciate  the  \\ritings  of  Pare,  they  should  be  compai'ed 
with  those  of  other  teachers  of,  or  writers  on,  surgery  of  his  day.  His 
treatise  upon  gunshot  wounds  may  be  compared  with  several  small  trea- 
tises on  surgery  pul)lished  in  the  latter  half  of  the  century,  thirty  or 
forty  years  after  the  appearance  of  his  treatise  on  this  subject,  and  written 
in  French  for  the  benefit  of  the  barber  surgeons.  Take,  for  example,  the 
Traitte  des  arcbumdes  of  Joubert,  published  at  Lyons  in  1574.  Laurens 
Joubert  (1529-83)  was  a  distinguished  physician  of  Mont])ellier,  ]>ro- 
fessor  of  medicine  in  the  university  and  dean  of  the  faculty.  He  had 
served  in  the  royal  army  in  the  campaign  of  1569,  where  he  ought  to  have 
heard  something  of  Pare's  methods  of  treatment,  but  he  makes  no  allu- 
sion to  them,  unless  it  be  where  he  speaks  of  the  oil  of  puppies  as  an 
anodyne.  His  Surgery  is  that  of  John  de  Vigo,  written  in  a  diffuse, 
pedantic  style,  which  was  probably  impressive  to  the  barbers  in  jiropor- 
tion  to  their  inability  to  understand  the  meaning  of  his  words.  At  one 
time  he  was  called  in  as  an  uni))ire  in  an  argument  between  a  physician 
(Veyras)  and  the  surgeon  of  the  king  of  Navarre  (Guilhemct)  as  to 
whether  gunshot  wounds  are  contused  and  should  be  treated  by  poultices, 
etc.  or  by  desiccatives,  as  by  washing  with  wine.  The  arguments  on 
both  sides  and  Joubert's  decision  were  published  in  a  curious  little  book 


THE  HISTORY  AND  LITERATURE  OF  SURGERY.  51 

entitled  Tracite  dv  Vhiinirgie,  contcnant  i-raye  methode  de  r/ucrir  plai/es 
d\irquebumde,  etc.,  par  ]M.  Jaeqiies  Vtyras,  docteur  en  Medecine,  &  M. 
Tannequin  Guilhemet,  Chirurgien  du  Eoy  de  Navarre  (Lyon,  1581,  8°). 
Jonbert's  decision  was,  upon  the  whole,  in  favor  of  the  views  of  the 
plu'sician,  as  was  to  be  expected.  He  refers  to  Pare  as  "  homme  digne 
foy,"  not  with  reference  to  his  treatment  of  wounds,  but  to  his  statement 
that  bones  may  be  fractured  by  the  wind  of  a  cannon-ljall — this  lieiug 
precisely  one  of  the  points  on  which  Pare  was  wrong. 

The  lirst  teaching  in  French  given  to  the  barbers  and  surgeons  was 
by  a  physician,  Jean  Canape  of  Lyons,  physician  of  Francis  I.,  who  in 
the  first  half  of  the  century  gave  public  lectures  to  them,  and  for  the 
same  purpose  translated  into  French  a  compend  by  Guy  de  Chauliac 
(Lyons,  1538,  12°  ;  also  1563-71),  some  anatomical  treatises  of  Galen 
(Lyons,  1541),  and  several  other  small  treatises. 

Pierre  Tolet  (1502-8?),  a  surgeon  of  Lyons,  in  1540  published  a 
translation  into  French  of  the  sixth  Book  of  Paulus  ^gineta.  In  his 
prefatory  letter  to  this,  addressed  to  the  French  surgeons,  he  refers  to 
Jean  Canape  as  a  man  to  whom  surgery  owes  more  than  to  any  man  who 
has  written  since  (Jalen. 

In  1570,  .Taeipies  Dalechamps,  pliysician  and  reader  in  surgery  at 
Lyons,  published  Vhlrurgie  Framjoise  as  a  manual  for  the  barber  sur- 
geons. It  consists  of  the  sixth  book  of  Paul  of  ^Egina,  Hippocrates  on 
fractures  and  dislocations,  and  extracts  from  Celsus,  Albucasis,  etc., 
witii  the  annotations  of  Dalecliamps,  and  a  brief  treatise  on  operations 
by  Jean  Girault,  master  surgeon  in  Paris. 

In  1583,  Esaie  le  Lievre,  surgeon,  published  a  little  book  entitled 
Ojfieinne  et  Jurdin  de  Chirurc/ie  mUitaire  contenant  les  instrumentz  et 
pinnies  tves  necessaires  a  tous  Chinur/ieiw,  etc.  The  general  style  of 
this  work  may  be  seen  in  the  following  sentence :  "  Nous  disons  I'har- 
quebnzade  on  jilaye  faicte  par  harqucbuze  ou  canom  ;  estre  une  aiFection 
contrc  nature,  portant  de  foy  plusienrs  especes  d'accidens ;  a  scavoir 
extreme  contusion,  combustion,  diruption,  dilaceratio,  concution,  frac- 
tion, fracation,  j)uis  repercution,  abolitions,  destructions,  extinctions,  ou 
mortifications,  selon  plus  ou  moings,  des  espritz  tant  vitaux,  animaux,  que 
naturels :  de  laquelle  complication  assemblee,  selon  la  nature  tt  noblesse 
des  parties  offensees,  se  forme  une  indisjiosition  tendant  a  reudre  ladite 
partie,  consequement  tout  le  subiect  en  cadaver." 

The  Sclopetarim  of  Quereetanus  (Du  Chesne)  (Lyon,  1576)  is  a 
wortliless  book  by  a  notorious  charlatan.  It  was  translated  into  Eng- 
lish and  published  at  London  in  1590  by  a  certain  John  Hester,  who 
offered  for  sale  the  Arcana  prescribed  therein.  Care  is  taken  to  give 
two  sets  of  remedies — one  for  the  injuries  of  the  common  soldiers,  the 
other  "  to  be  used  for  the  rich."  For  advertising  purposes  the  same 
John  Hester  published  .1  .S7(o/-/  TH.^cmirs  of  the  e.rccUent  Doctour  and 
Kiiif/lit,  ma'ifiter  Leonardo  Fhiorcircuiti,  Bolognese,  uppoii  Chirurgerie 
(London,  1580),  advertising  at  the  end  that  he  is  pi'epared  to  furnish 
various  salves,  philosoj)hical  oils,  and  other  preparations  recommended 
in  it.  Phioravanti  explains  that  "the  reason  why  white  of  egg  is  to  be 
used  in  mixing  ajiplications  for  wounds  is  because  the  white  is  that  ])art 
which  produces  the  flesh,  the  skin,  and  the  feathers  of  the  hen,  while 
the  yolk  engendereth  only  the  intestines.     Therefore  the  white  is  like 


62  THE  THSTORY  AND  LITERATURE  OF  SURGERY. 

unto  flcsli,  aiKl  its  special  business  is  to  produce  it."  He  says  also  that 
the  most  perfect  remedy  for  a  great  flux  of  blood  from  a  wound  is  to 
stitcli  it  close,  and  then  take  dry  human  blood-[)o\\dcr  and  lay  it  upon 
the  wound.     This  is  tiie  same  as  the  mummy  of  I'aracelsus. 

Tiic  reference  made  by  Pare  as  to  the  value  of  the  instruction  whicli 
he  obtained  in  the  Hotel  Dieu  is  perhaps  the  tirst  allusion  to  the  imi)urt- 
anee  of  hospitals  as  a  means  of  furnishing  instruction  in  surgery.  Hos- 
pitals had  existed  since  before  the  Christian  era  in  India,  and  those  in 
Persia  under  the  Nestorians  were  really  used  for  educational  purposes 
in  connection  with  their  medical  schools.  The  foundations  of  many 
European  hospices  and  hosjiitals  date  from  the  tenth  and  twelfth  cen- 
turies, such,  for  example,  as  the  San  Spirito  at  Rome  and  St.  Bartholo- 
mew's and  St.  Thomas's  in  London,  some  of  the  impulse  to  the  forming 
of  such  institutions  apparently  having  come  from  the  need  of  providing 
them  for  lejiers. 

No  surgical  instruction  appears  to  have  been  given  in  the  hospitals 
of  the  Middle  Ages,  exccjit  that  the  surgeons  connected  witii  them  may 
have  employed  some  of  their  apprentices  to  assist  them  in  the  bandaging 
and  in  the  dressing  of  wounds ;  but  what  we  know  as  "  clinical  surgery  " 
was  an  aifair  of  nuich  later  date. 

Of  the  immediate  j)upils  and  followers  of  Pare,  the  most  important 
were  Pierre  Pigray  (15o.j-161.j),  whose  published  works  are  mainly 
abstracts  and  translations  of  Pare;  and  Jacques  Guillemeau  (1550-1012), 
surgeon  of  Charles  IX.,  Henry  III.,  and  Henry  IV.,  and  surgeon  of 
the  Hotel  Dieu,  who  accjuired  tame  as  a  writer  and  teacher  in  surgery, 
obstetrics,  and  ophthalmology.  His  La  chirurgic  fmnqolse  (Paris,  1594, 
folio)  was  translated  into  Dutch,  and  thence  into  English,  and  published 
at  Dort  in  lo!t7  under  the  title  of  The  French  < 'hin(r(/ci-ifc,  i'orimng  a, 
beautifully  printed  and  illustrated  foliii,  winch  was  much  the  best  work 
on  this  subject  which  had  then  appeared  in  English.  Guillemeau  Avas 
unusually  well  educated  for  a  surgeon  of  those  days,  having  studied 
under  Riolan  as  well  as  under  Pare,  and  he  tried  to  harmonize  the 
statements  of  the  latter  and  those  of  his  op])onent,  Gourmelin,  by  saying 
that  Galen  recommends  the  cautery  in  amputation  for  gangrene,  and  aji- 
proves  the  use  of  the  ligature  for  hemorrhage  when  there  is  no  corruption. 

Par4  in  advising  the  ajiplication  of  the  ligature  says  it  does  not 
matter  if  some  other  tissue  besides  the  vessel  is  included  in  it ;  but 
Guillemeau  says  that  a  portion  of  such  tissue  is  to  be  included  :  "  prenant 
quelquc  portion  de  chair  ensemble,"  evidently  thinking  that  this  is  an 
important  feature  of  the  o})eration. 

His  chapter  on  aneurism  contains  an  account  of  a  case  of  traumatic 
aneurism  at  the  bend  of  the  elbow  in  which  he  applied  a  single  ligature 
above  the  swelling  M'ith  success.  In  this  case  the  aneurism  had  ruptured, 
and  after  ligating  the  artery  he  opened  it  further  and  turned  out  the 
clots.  This  one  ligature  A\as  j)laced  three  fingers'-breadth  aliove  the 
tumor.  Park's  description  of  the  operation  also  refers  to  the  use  of  but 
one  ligature,  and  not  to  tlie  operation  of  Antyllus. 

There  were  no  surgeons  of  repute  in  Germany  prior  to  the  middle 
of  the  fifteenth  century ;  they  were  almost  all  barbers,  who  could 
neither  read  nor  write.  In  1868  there  Avas  for  the  first  time  pub- 
lished a  manuscript  treatise  on  surgery  Avritten  in  German  about  1460 


THE  HISTORY  AND  LITERATURE  OF  SURGERY.  53 

by  Hc'inricli  Pfolzju-iuidt,  and  entitled  BiiinHh-Ertznei.  This,  the  oldest 
German  work  on  surgery  at  present  known,  relates  mainly  to  the  treat- 
ment of  wounds,  but  it  contains  a  remarkable  chapter  on  the  making 
of  a  new  nose  from  the  skin  of  the  arm  after  the  method  of  Branca. 
There  is  an  allusion  to  the  burning  t)f  wounds  by  powder,  but  no  refer- 
ence is  made  to  lithotomy  or  to  operations  for  hernia.  It  gives  a  receipt 
for  a  narcotic  mixture  to  be  inhaled  from  a  sponge  similar  to  that  men- 
tioned by  Guy  de  Chaidiac.  The  first  German  surgeons  of  repute  whose 
works  have  come  down  to  us  are  Hieronymus  Bnmschwig,  and  Hans 
von  Gersdorff,  called  Schylhans  or  Schieliians,  both  being  surgeons  at 
Straslinrg  in  the  last  half  of  the  fifteenth  century.  Erunschwig  was 
born  about  the  middle  of  the  fifteenth  century,  and  published  at  Stras- 
burg  in  1497  a  folio  volume  with  the  title  Din  id  da-s  biwh  dcr  Viruryki, 
Ilmdwirck  der  Wundartzny  von  Hyeronimo  brunschwig.  Of  this  there 
were  eight  other  editions,  the  last  at  Augsburg  (1539,  quarto).  The 
Washington  Library  has  the  folio  editions  of  1508  and  1513  and  the 
quarto  editions  of  1533  and  1539  ;  also  the  English  translation  of  1525, 
and  a  Dutch  translation  in  folio  printed  at  Utrecht  in  1535.  The  Eng- 
lish translation  is  the  first  book  on  surgery  in  English,  and  its  title-page 
is  a  curiosity  in  itself.     It  begins  as  follows  : 

"  The  noble  experyence  of  the  vertuons  handywarke  of  surgeri  prac- 
tysyd  &  compyled  by  the  nioost  expertc  ]Mayster  Jherome  of  Bruyns- 
wyke  borne  in  Stracsborowe  in  Almayne  yi'  whiciie  hath  it  fyrst  proved 
and  trewly  foiuide  by  his  awnc  dayly  exercysynge." 

This  title  is  the  work  of  the  unknown  translator,  who  has  also  given 
a  short  })rcfaci',  in  which  he  siiys  that  "it  is  oftentymes  sene  and  dayly 
chaunceth  in  small  townes,  borowghs  and  villages  that  dyverse  people 
hurt  or  dyseased  for  lacke  of  connynge  men  be  taken  in  hande  of  them 
tliat  lie  barbers  or  yonge  maisters  to  whome  this  sciens  was  never  dys- 
closed,  not  thynkynge  on  the  wordes  of  the  olde  lernyd  men  that  say, 
It  is  not  wel  possible  to  man  that  he  sholde  bryngt'  well  to  a  good  end 
the  thynge  wliiche  ho  never  or  hath  but  lytell  seen." 

Brunschwig's  book  was  the  first  in  which  any  definite  statement  is 
made  about  gunshot  wounds,  or,  as  the  English  translation  has  it,  "  of 
woundis  sliot  with  a  gone  whereas  the  venym  of  the  powder  abydyth  in." 
To  remove  the  venom  he  advises  to  pass  a  small  cord  of  hair  through 
the  wound  and  draw  it  back  and  forth,  after  which  a  tent  is  to  lie  placed 
in  the  womid. 

In  amputation  he  advises  either  the  actual  cautery  or  boiling  oil  to 
cheek  hemorrhage.  He  has  nothing  to  say  about  lithotomy,  herniotomy, 
aneurism,  or  tumors — the  book  biMug,  in  fact,  a  treatise  on  the  military 
surgery  of  those  days.  It  is  illustrated  with  large  quaint  wood-cuts 
which  are  anifiiig  the  earliest  sjiecimens  of  the  art.  Haeser  says  there 
were  two  English  translations — one  published  at  London,  and  the  other 
at  Soutliwark,  but  these  are  the  same  work. 

Hans  von  Gersdorff  was  an  army  surgeon  in  1476-77,  and  published 
his  book,  Fcldthuch  der  Wundtarzucfi  (in  folio),  at  Strasburg  in  1517. 
Of  this  there  were  eight  later  editions  and  translations  into  Latin  and 
Dutch.  The  Washington  Lil)rarv  contains  the  first  edition,  and  also 
the  Strasliurg  editions  of  1527  and  1540  and  the  Erankfort  edition  of 
1551.    Gersdorll"  treats  more  fully  of  shot-wounds  than  docs  Brunschwig. 


54  THE  HISTORY  ANT)  LITERATURE  OF  SURGERY. 

He  docs  not  consider  them  to  be  poisonous,  but  gives  detailed  directions 
for  findiiiu'  and  extracting  the  bullet,  with  figures  of  instruments,  and 
advises  tliat  tiie  powder  be  removed,  after  wliieh  warm  linseed  oil  is  to 
be  poured  int()  the  wound.  He  says:  "  I  do  not  know  of  any  l^etter  or 
milder  remedy  than  this,  which  1  have  learned  from  Master  Nicolaus, 
called  the  Maulartzt,  surgeon  to  Duke  Sigmund  of  Austria."  If  ampu- 
tation becomes  necessary,  he  says :  "  First  of  all  advise  the  jiatient  to 
resign  himself  to  God,  to  confess  his  sins,  to  remember  the  suffering  of 
our  Lord  witli  thanks,  and  the  surgeon  the  same  ;  tJuis  will  God  grant 
him  good  foi'tune  in  his  work.  And  when  you  will  cut  him  have  ready 
by  each  other  all  your  instruments  and  ap])aratus,  such  as  scissors,  knife, 
saw,  styptics,  bands  (lassbendel),  bandages,  pads,  tow,  eggs,  and  what 
belongs  to  it,  so  that  one  follows  the  other  in  the  order  of  the  operation, 
since  there  is  need  of  this.  And  when  you  are  ready  to  cut  let  some 
one  draw  back  the  skin  strongly  and  tie  a  band  firmly  around  it,  and 
place  another  band  in  front  so  tliat  a  space  of  a  finger-breadth  be  left 
between  the  two  bands  that  you  may  cut  between  them  with  tiie  knife  ; 
then  this  cut  is  quite  sui'e,  easily  made  and  makes  a  good  stump.  When 
j'on  have  made  the  cut  take  a  saw  and  divide  the  bone,  and  then  remove 
the  band  and  tell  some  one  to  draw  the  skin  over  the  Ijone  and  flesh  and 
hold  it  tight  in  front  ;  and  you  should  have  a  bandage  two  fingers  limad 
and  well  wetted  that  it  may  lie  smooth,  and  witli  it  bandage  the  thigh 
down  to  the  cut  that  the  flesh  may  go  in  front  of  the  bone,  and  leave  it 
thus  bound.  And  you  need  not  fear  bleeding  if  you  have  done  as  above 
described.  Bind  now  over  the  styptic  a  good  thick  pad,  take  the  bladder 
of  a  bull,  ox,  or  hog,  one  which  is  strong,  cut  the  neck  open  so  that  it  will 
go  over  the  pad  and  stumj),  and  the  bladder  should  be  wet  but  not  too 
soft ;  draw  it  tlien  over  all,  tie  it  hard  with  a  band  and  you  need  have 
no  care  about  the  bleeding." 

The  following  is  the  styptic  referred  to  :  "  Take  of  unslacked  lime 
two  ounces,  vitriol,  alum,  each,  one  ounce,  of  aloes  to  be  calcined,  gall- 
nuts,  colophony  each  a  quarter  of  an  ounce  ;  of  the  residuum  in  the 
retort  when  you  make  aquafortis  two  and  a  half  ounces,  and  the  white 
hair  of  the  belly  of  a  hare  or  deer  chopped   up,  and  mix  all  together 

thoroughly.     When  you  use  it  mix  it  with  white  of  eggs But  if 

an  artery  rages  and  will  not  be  staunched  then  burn  it  with  a  cautery." 
Although  he  used  no  ligature  in  am]iutation,  he  does  advise  a  double 
ligature  on  a  wounded  blood-vessel.  He  has  a  chapter  on  leprosy,  but 
says  nothing  definite  about  syphilis.  The  plates  in  Gersdortf 's  book  are 
especially  interesting. 

Walter  Hermann  Ryif  was  also  a  Strasburg  surgeon  of  the  first 
part  of  the  sixteenth  century,  and  published  a  number  of  treatises  in 
German,  his  Gross  Ckirurgci  appearing  in  1545,  and  his  Kleiner 
C'hirurr/i  in  1551.  This  tendency  to  depart  from  scholastic  methods 
received  a  strong  impulse  from  the  sayings,  doings,  and  writings  of 
Philippe  Aureole  Theophrastus  Bombastes  de  Hohenlieini,  lietter  known 
as  Paracelsus  (1493-1541).  He  was  born  in  the  village  of  Einsiedeln, 
near  Zurich,  studied  medicine  with  his  father,  travelled  extensively, 
studied  chemistry  and  alchemy  \\ith  Sigismund  Fugger,  and  served 
as  an  army  surgeon  in  eam]>aigns  in  Italy  and  the  Netherlands.  Of 
unbounded  self-assurance  and  ha\  ing  a  knowledge  of  some  new  rcme- 


THE  HISTORY  AND  LITERATURE  OF  SURGERY.  55 

dies,  such  as  antimony,  arsenic,  and  mercury,  he  soon  acquired  a  great 
reputation,  and  in  1526  was  appointed  professor  of  medicine  in  the 
University  of  Basle.  He  is  eliaraeterized  by  Dalton  as  "a  rampant, 
blatant,  boasting,  ignorant  vagalionil,  with  a  face  of  bi'ass  and  a  tongue 
like  a  race-horse,"  and,  if  the  word  "  ignorant "  be  omitted,  it  is  a  true 
picture.  But  he  \v"as  also  a  sort  of  genius,  in  a  way  a  poet ;  and,  knave  and 
charlatan,  and  in  his  latter  days  drnidvard,  though  he  was,  his  doctrines 
were  accepted  by  such  men  as  Frobenius,  Erasmus,  and  Van  Helmont, 
anil  had  a  powerful  influence  throughout  Europe  for  a  century  or  more, 
some  of  his  pecidiar  theories  still  surviving  as  the  essence  of  modern 
homceopathy.  He  wrote  or  dictated  many  works,  of  which  the  only 
one  that  need  be  mentioned  here  is  Der  grotmen  Wundartzney  (15.36-37), 
of  which  there  were  several  editions,  besides  Latin  and  French  transla- 
tions. The  second  chapter  begins  as  follows  :  "  It  is  necessary  to  know 
in  the  first  place  what  is  the  efficient  cause  of  the  curing  of  wounds, 
because  this  may  of  itself  indicate  the  proper  treatment.  Know  then 
that  the  human  body  contains  in  itself  its  own  proper  radical  lialsam, 
born  in  it,  and  with  it,  and  not  only  the  body  as  a  \vhole  contains  it, 
but  all  its  parts,  such  as  flesh,  bones  and  nerves,  have  each  its  own 

peculiar  juice  competent  to  cure  wounds It  is  not  the  surgeon 

who  cures  wounds,  it  is  the  natural  balsam  (or  juice)  in  the  part  itself." 
Hence  he  inveighs  against  what  he  calls  "  the  damnable  precept  which 
teaches  that  it  is  necessary  to  make  wounds  suppurate."  Elsewhere 
he  calls  this  animal  juiee  "  la  mumie,"  but  he  also  meant  by  this  a 
special  preparation  made  from  certain  parts  of  the  human  body — 
something  like  the  animal  juices  and  extracts  whicli  have  been  re- 
cently recommended  as  remedies,  and  which  are  quite  Paracelsian  in 
character. 

The  ideas  of  Paracelsus  were  accepted  by  Felix  Wurtz  (1514-74)  of 
Basle,  who  studied  under  Ryft'  at  Nureml)erg,  and  was  on  terms  of  inti- 
macy with  Paracelsus  and  with  Conrad  Gesner,  the  most  learned  man 
of  his  time.  He  acquired  great  reputation,  and  published  his  Practka 
(ler  Wauflarziiet/  in  1563.  Of  this  about  fifteen  editions  appeared  during 
the  next  hundred  years,  including  an  Euglisli  translation  by  Fox,  pub- 
lished in  1656.  He  remarks  that  "skill  in  surgery  is  obtained  with 
great  painfulness,  for  it  is  not  gotten  witii  sitting  on  a  cushion  at  home 
and  by  reading  and  writing ;  ....  it  is  not  enough  to  be  full  of  talk, 
and  to  say  such  and  such  and  write  so  and  so, — a  patient  is  little  the 
better  for  it  if  the  surgeon  hath  no  skill  to  dress  his  wounds."  The  work 
is  almost  entirely  devoted  to  wounds  and  fractures  and  their  consequences, 
and  contains  nothing  as  to  the  teehni(]ue  of  surgical  operations.  The 
treatment  advocated  is  in  the  main  sinqjle  and  sensible.  Styptic  powders 
are  condemned  fi)r  general  use,  as  is  also  the  cautery  to  suppress  hemor- 
rhage, except  in  amputation  of  the  thigh.  No  allusion  is  made  to  the 
ligature,  and  it  is  not  probable  that  he  had  ever  seen  the  works  of  Pare. 
He  objects  to  the  probing  of  wounds,  declaring  tiiat  it  is  filly  to  feel  and 
grope  about  them,  and  tliat  some  surgeons  use  the  ]n'obe  merely  because 
tiuy  have  seen  it  used  and  to  show  that  they  are  doing  something.  Cat- 
aplasms and  poultices  for  fresh  wounds  are  condemned,  and  the  blood 
is  not  to  be  washed  or  squeezed  out,  "  for  it  is  a  right  flesh  glue  and 
hasteneth  the  healinar."     He  often  refers  to  the  conservative  surgeons 


56  THE  HISTORY  AND  LITERATURE  OF  SURGERY. 

who  say,  "Old  customs  should  not  be  abandoned,"  and  says,  "  ThcrcCore 
in  sonic  places  the  books  of  'J'lieophrastus  Paracelsus  (to  whom  the  best 
and  most  fiuiious  sur};-eons  must  give  place)  ai'c  prohibited  to  be  read  ; 
but  in  my  simple  judgment  it  is  done  vi'iy  tbolishly."  He  objects  to 
drawing  a  cord  through  a  gunshot  wound,  or  to  using  hot  oil,  or  to 
treating  such  injuries  otherwise  than  as  simple  wounds.  The  third  part 
of  his  book,  being  on  the  symptoms  and  complications  of  wounds, 
including  a  description  of  the  wound-fever  or  pyaemia,  is  the  most 
original  and  valuable  part  of  the  work. 

The  instruction  of  the  barber  surgeons'  apprentices  at  the  end  of  the 
sixteenth  century  appears  to  have  been  based  on  the  views  of  Jerome  of 
Brunswick,  if  we  may  judge  from  a  little  manual  by  Julius  Holder,  pub- 
lished at  Frankfort  in  1592,  entitled  DialoguH,  em  Niltzliche  niicl  Warh- 
(iff'tif/c  Bcurlircihinu)  dnes  rcchtc  Wundiniztti  mind  seiner  Jleixferschtiff. 
This  is  in  the  form  of  ijuestions  and  answers,  Latin  terms  being  curiously 
intermixed  with  the  (rerman. 

Another  good  specimen  of  the  sort  of  instruction  given  to  apprentices 
of  German  barber  surgeons  in  the  sixteenth  century  is  the  Wundartzney 
zu  alien  gebrechen  des  gantzen  Leibs,  etc.  of  Joannes  Charethanus  (or 
C'liaretanns),  of  which  five  editions  appeared  between  1530  and  155'5. 
The  edition  of  15411,  printed  at  Frankfort,  is  a  small  quarto  of  20 
leaves,  giving  directions  for  Itloodletting  and  tootli-pulling,  and  various 
formula  for  salves  and  potions.  It  directs  that  wounds  should  be  dressed 
twice  a  day;  that  he  who  i.s  wounded  in  the  head  shall  not  walk  about  or 
move  much  ;  that  he  shall  avoid  perspiring  and  talking,  which  inflame 
or  disturb  the  brain  and  make  him  insensible  ;  above  all,  he  shall  avoid 
strong  wine,  which  ])uts  him  in  deadly  peril;  likewise  the  rays  of  the  sun 
and  light  and  heat  and  indigestiljle  meat  and  the  society  of  woman,  whom 
he  shall  not  even  look  upon. 

If  a  large  ai'tery  is  cut  or  opened,  first  secure  the  same  carefully  with 
a  silk  thread  to  stop  the  bleeding  ;  then  lay  on  the  red  powder  and  cover 
with  a  red  plaster.  Let  it  remain  for  four  days  and  heal  it  like  other 
wounds. 

The  Seventeenth  Century. 

The  seventeenth  century  is  more  remarkable  for  the  advances  which 
were  made  in  jihysics  and  in  physiology  than  it  is  for  improvements  in 
surgery.  It  was  the  age  of  Francis  Bacon  (1561-l<)2(j),  of  (Jalileo  (15(54— 
1642),  of  Rene  Descartes  (1596-1650),  of  Pascal  (1623-62),  of  Sir  Isaac 
Newton  (1642-1727),  and  of  Robert  Boyle  (1626-91),  all  of  whom  had 
a  powerful  influence  in  developing  the  iatro-chemical  and  iatro-mechan- 
ical  theories  which  prevailed  about  the  end  of  the  ccnturv.  This  was 
also  the  ago  of  Borelli  (1608-79),  of  Thomas  Sydenham  (1624-89), 
and,  above  all,  of  William  Harvey  (1578-1657),  the  pupil  of  Fabricius 
d'Aquapendente,  whose  celebrated  work,  E.rercitatio  Andtoniica  de  Jlofu 
Cordis  et  Havgidnis,  appeared  in  1628. 

At  the  commencement  of  this  century  the  most  distinguished  Italian 
surgeon  was  Hieronymus  Fabricius  d'Aquapendente  (1537-1619),  who 
was  a  pupil  of  Fallopius  and  succeeded  him  as  professor  of  anatomy  at 
Padua.  He  was  the  discoverer  of  the  valves  of  the  veins  anil  the  teacher 
of  Harvey.     His  principal  discoveries  and  writings  relate  to  anatomy 


THE  HISTORY  ASD  LITEEATURE  OF  SURGERY.  57 

and  embryology,  Init  lio  was  also  professor  of  surgery,  and  his  Pcniatcu- 
chos  Chinitr/icnm  (f'rancof.,  1582)  and  his  Opera  Chirurgka  (Paris, 
1613,  in  folio,  and  later  editions)  were  important  works  of  reference 
during  tiie  next  century.  Fabrieius  was  learned  and  elocpient,  and  made 
the  University  of  Padua  the  nKjst  important  school  for  anatomy  and  sur- 
gery in  Europe.  His  surgery  is  mainly  tiiat  of  Celsus,  Paul  of  JEgina, 
and  Albucasis,  to  whom  he  gives  full  credit,  carefully  noting  the  sources 
of  his  ([notations.  No  great  advance  in  the  art  is  due  to  him,  but  his 
works  contain  manv  accounts  of  cases  and  references  to  tiie  metliods  of 
other  surgeons,  making  them  valuable  historically,  and  they  are  far  more 
interesting  as  a  piece  of  literature  tiian  is  the  corresponding  work  of  John 
de  Vigo.  In  speaking  of  wounds  of  the  intestines  he  refers  to  animal 
sutures  and  to  the  insertion  of  a  piece  of  the  trachea  of  an  animal  to 
preserve  the  lumen  of  the  gut.  He  describes  tracheotomy  and  urges  its 
performance  in  certain  eases,  and  says  tliat  lie  has  seen  one  case  of  cancer 
of  the  breast  cured  by  excision,  but  has  never  performed  the  operation 
himself. 

Next  to  him  came  Cesare  Magati  (1579-1647),  who  became  professor 
at  Ferrara  in  1612  (or  1621?),  and  who  gained  much  repute  by  his  book, 
De  rara  mcdieatlone  rulnenim,  fieu  de  vulnerihua  raro  fracfcaul ix  (\\hr\  ii., 
Venet.,  1616,  folio).  In  this  he  urged  a  simpler  mode  of  treating  wounds 
tlian  was  then  fasliionahlc,  advising  less  fre<pient  dressings,  eondenniing 
the  use  of  tents,  and  maintaining  that  gunshot  wounds  are  not  poisoned. 
His  doctrines  were  specially  urged  and  made  prominent  by  Sancassini  in 
the  early  part  of  tiie  eighteentli  century. 

Marcus  Aurelius  Severinus  (1580-1656),  professor  at  Na])les,  one  of 
tile  most  celebrated  teaciiers  of  anatomy  and  surgery  of  his  time,  is  best 
known  by  liis  book  De  recondita  abxcesnuuiii  naficra  (Naj)les,  1632, 
quart(j),  of  wliich  several  later  editions  were  publislied. 

Giovanni  Battista  Cortesi  (1554—1636),  a  barber's  apprentice,  after- 
M-ard  a  pu])il  of  Tagliacozzi,  whom  he  succeeded  as  professor  at  Bologna, 
publislied  a  treatise  on  wounds  of  the  head  in  1632,  and  a  manual  of 
surgery  in  1633,  wliicii  are  of  little  interest. 

Gaspar  Asellius,  the  discoverer  of  the  lacteals,  in  1623  was  professor 
of  surgery  and  anatomy  at  Pavia,  but  wrote  notiiing  on  surgery. 

Spigelius  (1578-1625),  a  native  of  Brussels,  professor  of  anatomy  and 
surgery  at  Padua  in  1605,  \vas  an  operator,  and  is  said  to  have  trephined 
the  same  jxitient  seven  times,  but  there  is  nothing  surgical  in  his  pub- 
lished w(n-ks.  Trephining  was  a  common  operation  at  this  time,  being 
employed  in  cases  of  insanity,  of  severe  lieadache,  and  of  clironic  diseases 
of  the  eyes,  as  well  as  for  injuries  of  the  skull. 

Pietro  de  Marchetti  (1589-1673),  professor  of  surgery  at  Padua, 
published  a  collection  of  cases  under  the  title  Observafionnm  medico- 
chiruir/icanini  xyllor/e  (Padua,  1664,  and  later  editions),  whicii  is  of 
permanent  liistorical  value.  Among  these  cases  is  one  of  successful 
trepiiining  following  a  dagger-wound  of  the  head  two  or  three  montiis 
previous,  and  several  cases  of  the  same  operation  for  headache.  Here 
also  is  the  celebrated  ease  in  which  a  pig's  tail  was  forced  into  the  anus 
of  a  prostitute,  and  was  removed  by  sli])ping  a  tube  over  it.  Pietro  was 
succeeded  in  the  chair  of  surgery  in  1()62  l)y  his  son  Dominique,  wlio 
accpiired  great  fame  as  a  teacluu-,  and  is  said  to  have  performed  neplirot- 


58  THE  irrsTonv  Axn  litebatuhe  of  simoERY. 

omy  successfully  without  being  guided  by  the  jjresence  of  any  tumefac- 
tion of  the  ])art. 

Filippo  Masiero,  a  surgeon  of  Padua,  was  the  author  of  the  follow- 
ing books:  II  chirunjo  in  j)ratfica,  etc.  (Venet.,  1688,  4to ;  5th  ed. 
1749,  8°),  //  mgno  chinur/iro  (Parts  I.,  II.,  Padua,  1697),  and  Opere 
chiruir/isclic  (Padua,  1707). 

Carolus  Musitanus,  a  physician  of  Najjles,  published  his  ( 'liinirr/ia 
theoretica  practiea  in  1698.  Haller  styles  him  "  improbabiliuni  histori- 
aruni  narrator." 

In  France  there  was  little  jn'ogress  in  surgery  until  near  the  end  of 
the  century.  The  medical  faculty  finally  triumphed  over  the  surgeons 
by  obtaining  a  decree  which  united  tlie  barl)ers  and  the  surgeons  in  one 
corjwration,  and  the  College  of  St.  Come  was  no  longer  a  jiower  in  the 
land.  Among  the  French  works  on  surgery  of  this  period  may  be  men- 
tioned Quelques  traites  des  operalions  de  chirurgie,  by  Jean  Girault  (Paris, 
1610) ;  Obficrrations  Medechiales  et  Chirurr/icales,  etc.,  of  Gul.  Loyseau 
(Bordeaux,  1617);  Observations  iatrocliirurgiqucs  of  Covillard  (Lyon, 
16."i9)  and  Le  Vhiturgien  Operatcur  of  the  same  author  (1633  ?;  2d 
ed.  Lyon,  1640);  Epintola  de  hiryngotomia  of  Rene  Morean  (Paris, 
1646);  La  Cliirurgie  Militaire  of  Leonard  Tassin  (Nimwegen,  1673); 
Les  opiratlons  de  la  chirurgie  of  J.  Bienaise  (Paris,  1688);  and  Traite 
des phij/es  d'arquebusade  of  Scipio  Abeille  (Paris,  1695). 

In  1696,  M.  de  la  Vauguion,  a  physician,  published  a  Traite  coinplet 
des  opendions  de  chirurgie  (8°,  Paris),  which  is  the  most  complete  man- 
ual in  French  prior  to  that  of  Dionis,  and  of  the  English  translation  of 
which  at  least  three  editions  were  published  (1699,  1707,  and  1716).  He 
names  the  tourniquet  and  describes  its  application  in  amputation  and 
in  the  operation  for  aneurism,  and  quotes  frequently  from  Fabricius 
Hildanus. 

Nicolas  de  Blegnv  (1652-1722),  surgeon  of  the  duke  of  Orleans  in 
1683,  the  founder  of  the  first  medical  journal,  published  a  treatise  on 
venereal  diseases  in  1673,  and  a  treatise  on  the  treatment  of  hernia,  with 
description  of  a  truss  of  his  invention,  in  1676.  He  is  also  the  author 
of  the  first  city  directory. 

Previous  to  the  seventeenth  century  surgery  had  made  little  progress  in 
the  Netherlands,  and  there  are  very  few  books  to  be  noted.  The  work  of 
Ypermans  has  already  been  referred  to.  CVirolus  Battus,  a  surgeon  of  Por- 
dreeht,  published  in  1590  his  Handtboeck  dcr  Chirurgijen,  of  which  tliere 
were  six  later  editions.     He  also  translated  the  works  of  Pare  into  Dutch. 

In  the  middle  of  this  century  Holland  became  celebrated  as  a  centre 
of  anatomical  and  surgical  teaching  through  the  labors  of  Tulp,  Bar- 
bette, Van  Meekren,  Van  Home,  Van  Roonhuysen,  Solingen,  Verduyn, 
and  others,  and  the  schools  of  Amsterdam  and  Leyden  began  to  draw 
students  from  all  parts  of  Europe. 

Paul  Barbette  (162?-7?),  son  of  a  Strasbui-g  surgeon,  studied  in 
Mont]jellier  and  Paris  and  settled  in  Amsterdam.  He  was  a  voluminous 
writer,  and  his  Chirurgie,  first  jiublished  in  Dutch  in  1657,  passed  through 
ten  editions  and  translations,  Ix'iug  a  pr)pular  manual,  while  his  Ojiera 
omnia  was  issued  twenty-two  times  in  various  languages.  He  first 
described  femoral  hernia,  suggested  laparotomy  in  intestinal  obstruc- 
tion, and  extirpation  of  the  spleen,  which  he  performed  on  dogs. 


THE  HISTORY  AyD  LITERATURE  OF  SURGERY.  59 

Job  Janszoon  Yan  Meekren  (■?-166(}),  a  native  of  Amsterdam 
and  a  pupil  of  Tulp,  was  a  celebrated  operator.  His  book,  Heel  ni 
genvexhonMiye  uumiierkingen  (Amst.,  1(J(J8),  was  translated  into  German 
and  Latin. 

Joh.  van  Home  (1621-70),  professor  of  anatomy  and  surgery  in 
Leyden,  was  a  distinguished  teacher,  but  his  writings  relate  mainly  to 
anatomv,  his  3IierofecIine  id  est  brerissima  Chiniir/iae  Methothin  (1(>()3) 
being  nierely  a  manual.  There  is  an  English  translation  of  this  (London, 
1717). 

Hendrik  van  Roonhuyscn  (1625-6?),  a  surgeon  of  Amsterdam,  also 
well  known  as  an  obstetrician,  published  his  Genees-en  Heelkonstuje 
aanmerfcingen  in  1672.  He  operated  for  wry-neck  and  hare-lip,  advised 
Caesarean  section,  removed  tumors,  and  seems  to  have  been  specially 
skilled  in  his  art. 

Cornelis  Solingen  (1641-87),  a  surgeon  at  the  Hague,  wrote  3Ianuale 
Operatien  der  Chirurgie  (Amst.,  1684),  which  Haller  says  is  full  of 
original  observations. 

Peter  A.  Verduyn  (162?-?),  a  surgeon  of  Amsterdam,  is  celebrated 
for  his  treatise  on  the  flap  method  of  amputation.  Diss,  de  nora  artuidii 
decitrtandonuii  ratiorie  {Am^t.,  16i»6).  He  seems  to  have  known  nothing 
of  the  similar  methods  of  Lowdliam.      (Sec  p.  ()7.) 

Joannes  Muys  of  Arnhcm  and  Leyden  jniblished  the  first  two  parts 
of  his  Pra.vis  Chirurgiae  rationalis  in  1683,  and  the  complete  work  in 
1695.  This  contains  accounts  of  one  hundred  and  twenty  cases,  some 
of  which  are  curious  and  interesting. 

Fabricius  Hildanus  (1560-1624)  is  sometimes  called  the  "Father  of 
German  Surgery,"  althougli  this  title  belongs  more  properly  to  Hcister. 
He  was  a  Swiss  by  birth,  and  for  the  last  twenty  years  of  his  life  was 
the  city  physician  of  Berne.  He  was  a  surgeon's  apprentice  who  man- 
aged to  acquire  a  good  classical  education,  and  probably  obtained  good 
practical  training  under  Griffon,  a  surgeon  of  Geneva.  He  travelled 
much,  resided  for  some  time  at  Cologne,  and  became  widely  known  as 
a  bold  and  skilful  i)]W'rator,  and  especially  as  a  lithotomist.  He  was  a 
strong  opponent  of  Paracelsus  and  his  friend  Wurtz,  and  was  a  volu- 
minous writer,  but  his  monographs  are,  for  the  most  part,  of  little 
interest,  the  best  being  his  Lithotomia  Vesicae  (Basle,  1626),  translated 
into  English  and  published  at  London  in  1640.  His  most  important 
])ublieation  for  readers  of  the  present  day  is  his  Obserrationnin  et  Curn- 
tioiiiiiii  Vhirurgienrum  Venfuriac,  in  wiiich  he  relates  his  experience  in 
a  large  number  of  siu'gical  cases  of  the  most  varied  character.  He 
advised  amputation  at  an  early  stage  in  gangrene,  and  that  the  incision 
should  be  made  in  the  sound  and  not  in  the  decayed  flesh. 

He  used  the  cautery,  and  not  the  ligature,  in  wounds  of  the  arteries, 
and  devised  a  number  of  complicated  instruments,  none  of  which  are 
of  practical  interest.  His  chief  influence  on  surgery  was  through  his 
correspondence  with  German  physicians  and  surgeons,  and  through  his 
urging  u])on  the  German  surgeons  the  necessity  for  the  study  of  anat- 
omy. His  Opera  omnia,  of  which  several  editions  were  published, 
appears  to  have  been  a  favorite  book  of  reference  for  surgeons  for 
many  years. 

John  Schultes,  better  known  as  "Scultetus"  (1595-1645),  a  pupil  of 


60  THE  IITSTOnr  AM)    UTEUATVriE  OF  SURGERY. 

Fal)riciiis  (rA(|ii:ii)i'ii(lc'iit(',  hccaiiu'  city  physician  at  Uini.  His  tjrcat 
M'oriv,  the  AniKiiiKnitdriiun  L'hirurgkmvi  (Uhii,  l()"j.'3,  folio),  passed 
thi'oiigh  many  editions  and  was  translated  into  many  languages. 

Joseph  Schmidt  (KiOl-?),  an  army  surgeon,  published  Spenilmn 
( 'lilruri/lcinii  (IJlin,  KJTjfJ,   quarto)  and  Kxatiwii    C/iiriirf/icujii  (Franeof., 

The  most  celebrated  (icrnum  surgeon  of  tiie  hitter  part  of  this  j)eriod 
was  Mattha'us  Gottfried  Purmann  (l(j4'j-1711  ?),  who  was  apprenticed 
as  a  barber  surgeon,  became  a  medical  oificer  in  the  Brandenlnirg  armv 
in  1675,  and  city  physician  at  Breslau  in  1685.  He  was  a  voluminous 
writer,  and  his  (r/'o.s.scr  vnd  f/cuitz  neu-f/ewuinJciier  Lorbcer-Krantz,  oder 
Wi'i nd-Artsuci/  [Franc(){.,  1692,  4to;  also  1722),  his  Chirurgiii  Curiosa 
(Franeof.,  1694,  4to;  translated  into  English,  Ivondon,  1706,  fob),  and 
his  Funftziy  nondcr-  uiid  iruiidcrbahre  /Schustswunden  Curen  (Franeof., 
1721)  are  valuable  works  in  the  history  of  the  art.  He  was  a  strong 
advocate  of  the  cure  by  the  M'ea]ion-salve  and  the  sympathetic  powder, 
and  tells  several  stories  of  the  successful  use  of  these  remedies.  He  used 
styptics  and  bandages  to  control  hemorrhages  after  amputations,  objecting 
to  the  eauterv,  l)ut  savs  nothintr  about  the  ligature. 

Here  may  also  be  mentioned  John  von  Muralt  (1 645-1 7;33),  a  dis- 
tinguished Swiss  anatomist  and  surgeon,  who  was  one  of  a  celebrated 
family  of  physicians  of  Zurich.  He  studied  at  Basle,  Leyden,  Oxford, 
and  Paris,  and  in  1761  returned  to  Zurich,  where  he  soon  became  dis- 
tinguished as  an  anatomist  and  surgeon.  In  1677  he  announced  jjublic 
lessons  in  anatomy,  M'ith  demonstrations  on  the  bodies  of  criminals  and 
of  persons  dying  of  remarkable  diseases  in  the  hospitals,  and  in  the 
same  year  published  his  Vade  Mecmn  Anatomicmn,  giving  the  date  by 
the  enlarged  letters  in  the  motto  of  the  book,  "  LVX  et  faX  IMcDICi"- 
nse."  In  the  second  edition  of  his  surgical  writings,  published  in  1711, 
he  describes  a  method  of  amputation  by  fla]>  devised  by  Saborian  in 
Geneva,  who  first  performed  it  in  1701,  and  this  is  by  some  claimed  to 
be  the  first  mention  of  that  method  of  operation,  but  it  had  already  been 
described  by  Yonge  in  1679.     (See  p.  67.) 

Other  German  surgeons  of  this  period  were  Mathias  Ludwig  Glandorp 
(1595-1636),  whose  iSpecidum  Vhlrun/icitm  appeared  in  1619  ;  Jessenius 
a  Jessen  (1566-1621),  author  of  Tnxfitutioncx  Vhinirgicac  (1601);  Paul 
Ammann  (1634-91),  author  of  Pntxix  vuincrum  lethaliiim  (Franeof., 
1690);  Joh.  Agricola  (1589-164?),  author  of  Chirurgia  parva  (Nurn- 
bei-g,  1643);  and  John  H.  Jungken  (1648-1726),  author  of  Compendium 
Chinur/icac  Mantndix  ahuofutum  (Franeof.,  1692). 

The  oldest  English  medical  book  -which  we  have  is  perhaps  the  Leech- 
book,  written  about  970  A.  d.,  and  printed  in  1865  as  volume  ii.  of  the 
Lecehdoins,  Worfeiinning,  ((»d  l-itarcraff  of  Early  England.  This  is  maiidy 
the  receipt-book  of  a  herbalist,  giving  the  uses  of  common  herbs,  and 
among  other  things  the  composition  of  various  "  wound-salves."  But  it 
also  contains  matters  taken  from  Paul  of  ^Fgina,  and  directs  :  "  If  thou 
must  carve  off  or  cut  off  an  unhealthy  limb  off  from  a  healthy  body,  tlien 
carve  thou  not  it  on  the  limit  of  the  healthy  body,  Init  much  more  cut  or 
carve  in  the  hole  and  (juick  body."  The  following  is  the  best  surgery  in 
the  book  :  "  For  hare-lip,  pountl  mastic  very  small,  add  the  white  of  an 
egg,  and  mingle  as  thou  dost  vermillion  ;  cut  with  a  knife  the  false 


THE  HISTORY  AND  LITERATURE  OF  SURGERY.  61 

edges  of  the  lip,  sew  fast  witli  silk,  then  smear  without  and  within  with 
the  salve,  ere  the  silk  rot.  If  it  draw  together,  arrange  it  with  the  hand  ; 
anoint  again  soon." 

In  the  hook  of  The  Pht/siciaiifs  of  Myddrni,  which  dates  from  about 
tlie  thirteenth  century,  there  are  a  few  references  to  surgical  opera- 
tions. Tile  autlior  says  (page  40) :  "A  wounded  lung  is  the  physician's 
third  tlitiiculty,  for  he  cannot  control  it ;  but  he  must  wait  for  the  will 
of  God.  By  means  of  herbs  a  medicine  may  be  prepared  for  any  one 
who  lias  a  pulmonary  abscess  [empyema].  He  should  let  out  [the 
matter]  and  support  [the  patient]  as  in  the  case  of  a  wounded  lung,  till 
lie  is  recovered.  But  most  usually  he  will  have  died  within  eleven  years 
[or  one  year]."  Page  44  :  "  A  hard  vesical  calculus  is  thus  extracted  by 
operation  :  Take  a  .staff  and  place  it  in  the  bend  of  the  knee ;  then  fix 
both  arras  within  the  knees,  doubling  them  over  the  staff,  and  securing 
both  wrists  with  a  fillet  over  the  nape  of  the  neck,  the  patient  (being 
placed  on  the  back),  his  stomacii  \\\^,  witli  some  supjiort  under  both 
thighs,  and  the  calculus  cut  for  on  tlie  left  side  of  the  urethra.  Let  him 
subsequently  be  jnit  in  a  water-bath  that  same  day,  also  the  day  follow- 
ing early,  and  after  this  he  should  be  put  in  the  kyfteitii.  Then  he 
should  be  removed  to  his  bed,  and  laid  tiiere  on  his  back,  his  wound 
being  cleaned  and  dressed  with  flax  and  salt  butter.  He  should  be  kept 
in  the  same  temperature  until  it  be  known  wliethcr  he  shall  escape  [effects 
of  the  operation].  He  should  be  kept  without  food  or  drink  for  a  day 
and  a  night  previous  to  the  operation,  and  should  iiave  a  bath." 

The  following  is  the  direction  for  an  antesthetic  (page  423) :  "  Take 
the  juice  of  orpine,  eringo,  poppy,  mandrake,  ground-ivy,  hemlock,  and 
lettuce,  of  each  equal  parts.  Let  clean  earth  be  mi.xed  with  them  and  a 
potion  prepared,  tlieii  without  doubt  the  patient  will  sleep.  When  you 
are  prepared  to  t)perate  upon  the  jjatient,  direct  tliat  he  shall  avoid  sleep 
as  long  as  he  can,  and  then  let  some  of  the  potion  be  poured  into  his 
nostrils,  and  he  will  sleep  without  fail. 

"  When  you  wish  to  awake  him,  let  a  sponge  be  pounded  in  vinegar 
and  put  in  his  nostrils. 

"  If  you  wish  tliat  he  should  not  wake  for  four  days,  get  a  penny- 
weight of  the  wax  from  a  dog's  ear,  and  the  same  quantity  of  pitch  ; 
administer  it  to  the  patient  and  lie  will  sleep. 

"  Wiien  you  would  that  he  should  awake,  take  an  onion,  compounded 
with  vinegar,  and  pour  some  into  his  mouth,  and  he  will  awake.  Take 
care  that  you  keep  him  quiet,  and  warned  of  the  operation,  lest  he  should 
be  disturljed." 

The  first  surgeon  in  England  of  whom  we  have  any  definite  account, 
and  wliose  writings  still  exist,  was  John  of  Arderne  (or  Arden),  born 
about  l."]08,  who  practised  in  Newark  until  about  1370,  when  he  went 
to  London.  He  wrote  a  treatise  on  surgery  of  which  several  manu- 
script copies  are  in  existence,  but  the-  only  work  of  his  which  has  been 
printed  is  ^1  trcuthc  of  the  fixfuld  in  the  fumhimenf,  or  other  placet  of  the 
bodt/,  etc.,  which  is  included  witli  the  translation  of  Arcffius  on  wounds 
of  the  head,  etc.,  printed  in  London  in  lo8S,  liciiig  a  translation  by  John 
Read.  His  operation  itself  consisted  either  of  slitting  up  the  fistula  or 
of  passing  a  thread  tlirough  it,  ^\•llich  is  to  be  drawn  so  as  to  cut  through 
the  flesh  graduallv. 


62  THE  HISTORY  AND  LITERATURE  OF  SURGERY. 

His  dcscriptiiiii  of  caiu'cr  of  tlic  rcctiini  is  a  graphic  one,  and  begins 
as  follows : 

"  Bubo  is  an  Apostunie  breding  within  the  fundament  in  the  longa- 
tion  with  great  hardness,  but  with  little  paine.  This  before  his  ulcera- 
tion is  nothing  but  a  hid  Cancer,  which  cannot  in  the  beginning  be 
knowne  by  sight  of  the  eye,  for  it  is  hid  within  the  fundament,  and 
therefore  it  is  called  Bulio.  For  as  an  Owle  hidctii  her  self  in  the  dai'ke 
places,  so  this  griefe  lurketh  within  in  the  beginning. 

"  Bnt  after  processe  of  time  it  is  ulcerat  and  frettith  and  goeth  out, 
and  oftentimes  it  frettith  and  ulcerith  all  the  circumference  of  the  funda- 
ment, so  that  the  excrements  goeth  out  contimiallie  without  retencion, 
and  may  never  be  staied  unto  the  death,  nor  cured  by  the  healpe  of  man. 
And  it  is  thus  knowen. 

"  Put  your  finger  within  the  fundament  of  the  pacient,  and  if  ye 
finde  within  a  thinge  very  harde,  sometime  on  the  one  side,  and  sometime 
on  both,  which  hindreth  egestion,  than  it  is  Bubo. 

"  And  the  manifest  signs  are  these.  The  patient  cannot  abstaine  from 
stoole,  for  aking  and  priking,  and  that  twise  or  thrise  within  an  lionre, 
and  the  excrementes  seeme  as  it  were  mingled  with  watrie  blond,  and  it 
stinkcth  very  strongly,  so  that  all  the  nnskilfull  surgions  and  the  patient 
also  thinketh  they  have  Dissenterium,  when  truel}'  it  is  nothing  so,  for 
Dissenterium  is  with  flux  of  the  belly,  but  in  Bubo  there  goeth  foorth 
hard  egestion  and  sometime  they  may  not  goe  out  for  straightnesse  of 
the  Bubo,  but  are  reteyned  within  the  fundament  straiglitly  so  that  ye 
may  feele  them  with  your  finger  and  drawe  them  out,  and  in  this  case 
glisters  availeth  much. 

"And  when  they  bee  nigh  their  ende,  they  beginne  to  have  lynger- 
ing  fevers,  and  to  loose  their  appetite,  tlie_y  forsake  all,  and  covet  wine, 
they  eate  little  and  covet  everieday  lesse  and  lesse,  they  sleepe  bnt  little 
and  unquietly,  they  are  heavie  as  well  in  niinde  as  in  body,  and  as  they 
waxe  weaker  and  weaker,  they  covet  their  bedde  and  above  all  thinges  to 
drinke  water,  neverthelesse  they  can  speake  and  move  themselves  to  the 
last  breath. 

"  From  these  (I  say)  wash  your  handes  if  you  have  care  of  j'our  credit, 
unlesse  it  be  in  glisters  as  aforesaide  to  ease  him." 

At  the  beginning  of  the  fifteenth  century  there  was  a  great  dearth  of 
surgeons  in  England,  as  it  appears  from  Rymer's  Fcedera  that  in  1417 
Henry  authorized  "  John  Morstede  to  press  as  many  surgeons  as  he 
thought  necessary  for  the  French  expedition,  together  with  persons  to 
make  their  instruments.'  With  the  army  which  won  the  day  at  Agin- 
court  there  had  landed  only  one  surgeon,  the  same  John  Morstede,  who 
indeed  did  engage  to  find  fifteen  more  for  the  army,  three  of  whom  were 
to  act  as  archers." 

Of  the  English  surgeons  of  the  fifteenth  and  sixteenth  centuries,  those 
whose  names  are  best  known  are  Vicary,  Gale,  Clowes,  and  Lowe. 
Thomas  Vicary  (149?-1561),  the  first  master  of  the  Amalgamated  Bar- 
bers and  Surgeons  in  1541,  and  one  of  the  first  governors  of  St.  Bar- 
tholomew's, published  in  1548  a  work  on  anatomy  in  English.  No  copy 
of  this  edition  is  known  to  exist,  but  the  edition  of  1577  was  reprinted 
by  the  Early  English  Text  Society  in  1888.     Thomas  Gale  (1607-86),  a 

'  The  Antiquary's  Portfolio,  by  J.  S.  Forsyth,  vol.  i.,  London,  1835,  p.  80. 


THE  HISTORY  AND  LITERATVRE  OF  SURGERY.  63 

native  of  London,  served  in  the  army  of  Henry  VIII.  in  France  in  1 544, 
and  nnder  Piiilip  II.  of  Sjmin  in  1577,  succeeded  Vicary  as  master  of 
the  Barber  Surgeons  Company  in  1561,  and  in  1563  published  \\is,  Lwti- 
tui'ion  of  Chirurfferie,  with  other  treatises,  one  of  whicii  is  Of  icounds 
made  with  Gonuetihof,  in  whicii  lie  opposes  the  views  of  Brunswiclv,  De 
Vigo,  and  Fcrrius  as  to  the  venomous  nature  of  such  wounds,  and  quotes 
Maggius  approvingly.  He  advises  styptics  in  amputations — says  that 
his  method  is  used  in  St.  Thomas's  Hospital,  and  gives  cases  to  prove 
that  bullets  may  be  left  in  the  body  without  danger. 

William  Clowes  (1540-1624)  was  at  first  a  naval  surgeon,  and  became 
surgeon  of  St.  Bartholomew's  in  1581.  He  wrote  A  proved  practise  for 
all  young  C'hirurcjions  concerning buniingn  with  Gnnpowder  and  Woundes 
made  with  Gunshot,  etc.  (London,  1  SOI  ,'.S°  ;  3d  ed.  1637,4°).  He  refers 
to  Pare  as  a  man  worthy  of  admiration,  and,  like  Gale,  comments  severely 
on  the  ignorance  of  the  so-called  surgeons  of  his  time.  Peter  Lowe 
(155?-161?),  a  Scotch  surgeon,  practised  for  a  long  time  in  France  and 
Flanders  and  as  an  army  surgeon.  In  159(5  he  \\as  in  London,  where 
he  published  his  works  on  the  Spanish  Sickness  and  The  Mliole  Course 
of  Vhirurgerie.  In  1598  he  returned  to  Glasgow,  and  founded  the  Fac- 
ultv  of  Phvsicians  and  Surgeons  of  Glasgow,  which  was  chartered  by 
King  James  VI.  in  1599.  His  book  on  surgery  passed  through  four 
editions,  and  is  a  good  manual  for  its  time.  In  amputation  for  gangrene 
he  used  the  actual  cautery,  but  says :  "  In  amputation  without  putrefac- 
tion I  finde  the  ligature  reasonal)le  sure  ]irii\i(ling  it  be  quickly  done." 
This  is  perhaps  the  first  mention  in  Kuglisli  of  the  ligation  of  arteries  in 
amputation.  In  hernia  he  advised  the  pricking  of  the  intestines  with  a 
needle  to  discharge  the  wind  and  lessen  the  bulk  of  the  tumor. 

About  the  middle  of  the  sixteenth  century  there  lived  at  JMaidstone, 
Kent,  a  surgeon  named  John  Halle,  who  published  in  1565  a  translation 
of  the  (  'hirurr/ia  parva  of  Lanfranc,  with  some  remarksof  his  own,  entitled 
An  Historical  Expostulation  cdso  against  the  beastly  abusers,  both  of  Vhy~ 
rurgerie  and  Physiche  in  our  tymc :  With  a  goodly  doctrine,  and  instruc- 
tions necessary  to  be  marked  and  followed  of  all  true  Chirurgies. 

The  history  of  surgical  corporations  in  England  begins  with  the  bar- 
bers' guild,  which  was  at  first  a  meeting  for  social  and  religious  purposes, 
originating  probalily  in  the  thirteenth  century.  These  barbers  soon 
began  to  call  themselves  barber  surgeons.  There  were,  however,  sur- 
geons who  were  not  barbers,  some  of  whom  had  served  in  the  army,  and 
in  1368  these  surgeons  formed  a  separate  guild,  which  about  1421  com- 
bined with  the  physicians.'  The  barbers  obtained  a  eliarter  of  incorpora- 
tion from  King  Edward  IV.  in  1462. 

There  is  notiilng  in  the  charter  about  bnrl)cry — that  is,  shaving  and 
hair-cutting — Iiut  a  good  deal  about  the  regulation  of  surgery.  In  1492 
arms  were  granted  to  the  "  Guild  of  Surgeons,"  whicii  appears  to  have 
been  a  small  body  of  eight  or  ten  men  superior  in  social  position  to  the 

'  The  details  of  the  quarrels  between  the  barbers  and  the  surgeons,  and  of  the  organ- 
ization and  ])rogress  of  the  guilds,  will  lie  found  in  The  Annals  of  the  Barber  Siirgeonx  of 
London,  compiled  by  l^idney  Young  (a  thick  quarto  volume  published  in  1S90),  and  in 
The  Ch-aft  of  Siirf/ery,  by  J,  Flint  South  (published  in  1886).  The  act  of  Parliament 
passed  in  1540,  allowing  the  United  Companies  of  Barbers  and  Surgeons  to  have  yearly 
four  bodies  of  criminals,  was  the  first  law  in  the  country  for  promoting  the  study  of 
anatomv. 


64  THE  HISTORY  AM)  MTEUATURE  OF  SVIWKRY. 

l)arber.s.  In  1540,  uikUt  the  rcitrn  of  Hciirv  VIII.,  tlie  barbers  and 
the  surgeons  were  united  and  incorjiorated  In-  act  of  Parliament  as  the 
Company  of  tiie  Barber  Surgeons,  tiie  first  inastei'  Ijeing  Thomas  Vieary. 

lu  the  year  1542  an  act  was  j)assed  regulating  the  j)raetiee  of  surgery, 
stating  that  "the  Company  and  Fellowship  of  Surgeons  of  London, 
minding  their  owne  lucres,  and  nothing  the  profit  or  ease  of  the  diseased 
or  patient,  have  sued,  troubled,  and  vexed  divers  honest  persons,  as  well 
men  as  women,  whom  God  hath  endueed  with  the  knowledge  of  the 
nature,  kind  and  operation  of  certain  herbs,  roots  and  waters,  and  the 
using  and  ministering  of  them,  to  such  as  have  been  ]iained  «ith  custum- 
able  diseases,  as  women's  breasts  being  sore,  a  pin  and  the  web  in  the  eye, 
uncomes  of  the  hands,  scaldings,  burnings,  sore  mouths,  the  stone,  stran- 

guary,  saucelin,  and  morphew,  and  such  other  like  diseases And 

yet  the  said  persons  have  not  taken  anything  for  their  jiains  or  cunning. 
....  In  consideration  whereof,  and  for  the  ease,  comfort,  succour,  help, 
relief,  and  health  of  the  King's  poor  subjects,  inhabitants  of  this  his 
realm,  now  pained  or  diseased.  Be  it  ordained,  etc.  that  at  all  time  from 
henceforth  it  shall  be  lawful  to  every  person  being  the  King's  subject, 
having  knowledge  and  experience  of  the  nature  of  herbs,  roots  and 
waters,  etc.,  to  use  and  minister  according  to  their  cunning,  experience 
and  knowledge,  ....  the  tiforesaid  statute  ....  or  any  other  Act 
notwithstanding." 

The  Barber  Surgeons  had  public  demonstrations  of  anatomy  and  dis- 
sections in  their  hall,  but  it  was  forbidden  that  any  of  them  should  make 
dissections  or  give  lectures  on  anatomy  at  any  place  fithcr  than  said  hall. 
The  reader  in  anatomy  was  for  many  years  a  ])hysician. 

In  l(i()4  the  comjwmy  was  presented  with  five  hundred  copies  of  the 
Tables  (if  Surf/er}!  of  Horatius  Morns,  a  Florentine  physician,  translated 
by  Kichard  Caldwell'  (London,  1585,  .32  pp.  8°).  These  books  were 
given  by  j\Ir.  Caldwell  to  be  distributed  among  the  surgeons  who  were 
freemen  of  the  company. 

In  1643,  Edward  Arris  gave  to  the  corporation  the  sum  of  two  hun- 
dred and  fifty  pounds  for  the  pur^iose  of  having  one  human  body  pub- 
licly dissected  and  six  lectures  thereupon  read  each  year. 

The  Gale  Lectureship  was  tbunded  by  Dr.  Gale,  the  order  being  issued 
in  l(i98.  These  two  bequests  are  now  combined  and  the  lectures  in  con- 
nection with  them  are  known  as  the  Arris  and  Gale  Lectures. 

One  of  the  lecturers  before  the  Barber  Surgeons  was  Alexander  Read 
(or  Rhead),  a  Scotchman,  who  graduated  in  1620  at  Oxford.  His  Lec- 
turei<  on  wounds  were  published  in  1(534,  those  on  tSiirc/ical  operations  in 
1637,  and  all  his  works  in  1650.  Read  taught  that  a  bullet  may  be  so 
made  that  it  will  make  a  poisonous  wound,  quoting  as  authority  Querce- 
tanus.  Speaking  of  ligature  of  the  artery,  he  says  :  "  Ambrose  Parrey 
■would  have  this  mean  to  be  used  after  the  amputation  of  a  member,  whom 
you  may  read  ;  but  in  my  judgment  his  practice  is  but  a  troublesome  and 
dangerous  toy  ;  as  he  shall  finde  who  shall  go  to  make  trial  of  it." 

An  important  part  of  the  business  of  the  Corporation  of  Surgeons  was 

'  The  Dr.  Caldwell  referred  to  was  Richard  Caldwell,  a  graduate  of  O.xford  and  a 
physician,  and  president  of  the  college  in  loT(l.  Through  his  intlnence  Lord  Luniley 
founded  and  endowed  a  lectureship  on  surgery,  which  is  still  known  as  the  Lumleian 
Bequest. 


THE  HISTORY  AXD  LITERATURE  OF  SURGERY.  65 

the  examining  and  licensing  of  naval  snrgcons,  both  for  the  royal  navy 
and  for  merchant  ships.  An  account  of  such  an  examination  is  given  by 
Smollett  in  his  novel  Boderick  Bandom.  Oliver  Goldsmith  also  pre- 
sented himself  for  examination  in  1758,  and  the  minutes  of  the  court  of 
examiners  read  as  follows  :  "  James  Bernard,  mate  to  an  hospital ;  Oliver 
Goldsmith,  found  not  qualified  for  dito." 

In  Scotland  the  University  of  Aberdeen  was  founded  in  1494,  and  in 
1505  had  a  professor  of  medicine. 

King  James  III.  is  reported  to  have  been  "ane  singular  gude 
chirurgian,  and  there  was  none  of  that  profession  if  he  had  any  danger- 
ous cure  in  hand  but  would  have  craved  his  adwyse."  His  method  of 
obtaining  practice  must  have  been  effectual,  although  it  was  an  unusual 
one.  \ie  find  in  the  accounts  of  the  treasurer  for  1511  an  entry  as  fol- 
lows :  "  Item  to  one  fallow,  because  tiie  King  pullit  forth  his  tootht, 
xiiii.  5." 

The  first  charter  of  the  Royal  College  of  Surgeons  of  Edinburgh  is 
dated  July  1,  1505.  It  directs  that  no  person  shall  make  use  of  the 
craft  of  surgerv  or  of  barber  craft  within  this  burgh  unless  he  is  freeman 
and  burgess  of  the  same,  and  that  he  must  be  examined  by  the  masters 
of  the  same  craft  upon  the  following  points — namely  :  The  anatomy, 
nature,  and  complexion  of  every  member  in  man's  body,  and  all  the 
veins  of  the  same.  Every  year  one  executed  criminal  was  to  be  given 
to  the  college  for  anatomical  purposes.  No  master  of  the  craft  shall 
take  any  apprentice  who  cannot  write  and  read.  Probably  the  most 
important  provision  was,  that  no  person  -within  the  burgli  shall  make 
or  sell  any  aqua  vite  except  the  masters,  mcml)ers,  and  freemen  of  the 
corporation. 

By  1589  it  had  become  the  custom  to  admit  barbers  at  a  lower  rate, 
but  tiiey  had  only  the  right  to  act  as  barbers,  being  specially  forbidden 
to  practise  surgery,  and  were  to  have  "  na  signe  of  chirurgie  in  their 
bughts  or  houses  oppcnlie  or  privatlie." 

In  the  early  part  of  the  seventeenth  century  the  leading  British  sur- 
geons were  Clowes  and  Lowe,  already  referred  to,  and  John  ^^\)odall 
(156?-164?),  who  had  served  as  an  army  surgeon,  and  about  1612  was 
elected  surgeon  to  St.  Bartholomew's  Hospital  and  likewise  surgeon-gen- 
eral to  the  East  India  Com])any,  which  last  gave  him  the  ap])ointing  of 
surgeons  and  mates  to  all  the  company's  ships.  In  1G17  he  published  a 
work  entitled  T/ir  Suir/eoiifi  Mate  or  Milifari/  i{-  Doincstiquc  Surgery. 
Discoursing  faithfully  &  plainly  the  method  and  order  of  the  Surgeons 
chest,  the  uses  of  the  instruments,  the  vertues  and  Operations  of  the 
Medicines,  and  the  exact  Cures  of  Wounds  made  by  Gun-shott,  etc. 
In  1628  he  published  a  work  entitled  Viatknim,  Being  fhe  Bafh-Wcnj  to 
The  Surgeotitt  Chefit.  Containing,  Chirurgical  Instructions  for  the 
yongcr  sort  of  Surgeons,  imployed  in  the  Service  of  his  Majestic,  or 
for  the  Common-Wealth  upon  anjt  occasion  whatsoever.  Intended 
chiefly  for   the   better   curing   of  Wounds  made  by  Gunshot.'      His 

'  These  works  were  afterward  pnblisheil  together  in  folio  in  l()o9,  1G53,  and  1658,  a 
separate  tille-p.age  being  given  to  each  work,  but  the  pagination  being  oontinnons.  The 
second  title-page  is  often  transferred  in  place  of  the  lirst  one,  which  has  been  lost,  lead- 
ing, on  careless  examination,  to  the  erroneous  supposition  that  tliey  are  two  entirely  dis- 
tinct works  of  the  same  date. 
Vol.  I.— a 


66  THE  HISTORY  AND  LITERATURE   OF  SURGERY. 

works  arc  not  specially  instructive,  hut  are  in  parts  very  good  reading. 
In  ani|)utatiou  he  recommends  tying  large  vessels,  especially  those  of 
the  thigli,  if  it  can  be  done,  but  he  seems  to  think  that  the  surgeon 
will  often  fail,  in  which  case,  as  well  as  for  the  smaller  vessels,  he 
recommends  buttons  of  astringent  and  caustic  powders. 

In  gangrene  Woodall  urged  amputation  in  the  mortified  instead  of 
the  sound  part — an  old  treatment  which  had  then  fallen  into  disuse. 
He  also' suggests  amputating  as  low  as  the  ankle  for  disease  of  the  foot, 
instead  of  just  below  the  knee,  as  was  usually  the  case.  He  had  never 
seen  the  actual  cautery  used  in  amjnitation. 

In  1648,  James  Cook  of  Warwick  published  his  MrUififliim  Cliirur- 
giae,  or  the  Harrow  of  Surgery,  a  manual  which  seems  to  have  been 
j)opular,  the  sixth  edition  in  1717  being  "licensed  by  the  College  of 
Physicians  and  fitted  for  the  use  of  all  sea-surgeons."  In  his  descrip- 
tion of  amputation  no  mention  is  made  of  the  ligature  of  arteries. 

The  greatest  English  surgeon  of  the  seventeenth  century  was  Eichard 
Wiseman  (1622-76),  sometimes  called  the  English  Pare.  He  was 
apprenticed  to  a  barber  surgeon  in  1637,  served  in  the  Dutch  navy  until 
about  1644,  when  he  joined  the  army  under  Charles  I.,  and  was  admitted 
to  the  Company  of  Barber  Surgeons  in  1651.  He  was  a  surgeon  in  the 
Spanish  navy  for  three  or  four  years,  and  in  166(1  joined  King  Charles 
II.  and  was  appointed  one  of  his  surgeons.  In  1672  he  ])ublished  A 
Treatise  of  VVoundx  in  an  octavo  of  277  pages.  In  1676  this  was 
enlarged  and  printed  in  a  large  folio  volume  under  the  title  Severall 
Chirurgieall  Treatm's.  There  were  eight  of  these  treatises — viz.  I.  Of 
tumors ;  II.  Of  ulcers ;  III.  Of  the  diseases  of  the  anus ;  IV.  Of  the 
King's  evil ;  V.  Of  wounds ;  VI.  Of  gunshot  wounds ;  VII.  Of  frac- 
tures and  luxations;  VIII.  Of  lues  venerea.  In  1686  this  was  pub- 
lished in  folio,  having  the  words  "  the  second  edition  "  on  the  title-page, 
although  it  was  really  the  third,  and  the  so-called  "  third  edition  "  (folio, 
1796),  \vith  the  title  Eight  Chirurgieal  Treatises,  etc.,  was  really  the 
fourth.  Other  editions  appeared  in  1705,  1719,  and  1734,  and  there  is 
a  spurious  edition  of  1692,  which  is  really  the  original  edition  of  1676 
Avith  a  new  title-])age. 

^V^iseman  used  the  complex  dressings  of  the  period,  but  knew  that 
simple  measures  produced  equally  good  results.  He  used  styptics  and 
cauteries,  and  not  the  ligature,  but  he  included  the  end  of  the  cut  vessel 
in  one  of  the  stitches  through  the  lips  of  the  Avonnd.  Being  a  personal 
friend  of  the  king,  he  used  his  influence  with  him  to  promote  the  inter- 
ests of  the  Barber  Surgeon's  Company.  His  Avorks  Avere  ncAcr  trans- 
lated, and  Ayere  A'cry  little  known  on  the  Continent,  lint  they  had  a 
decided  influence  on  the  improA'ement  of  the  art  in  Englantl. 

James  Yonge  (or  Young)  (1646-1721),  a  natiA'e  of  Plymouth  and  a 
naval  surgeon,  published  in  1679  a  little  book  of  120  pages  entitled 
Currus  Triumphalis,  e  Terebintho.  Or  an  account  of  the  many  admirable 
Vertues  of  Oleum  Terebinthinae.  3Iore  'particularly,  of  the  good  effects 
produced  by  its  application  to  recent  Wounds."  ....  And  lastly,  A 
new  Way  of  Amputation,  etc.  He  objected  to  Pare's  method  of  liga- 
tures in  amputations,  saying  that  it  is  "  a  Avay  ahyays  tedious,  often 
successless ;  and  AvhateA'er  A'aunts  the  Author  makes  of  it,  it  cannot  be 
so  secure  as  he  pretends ;  it  being  liable  (sometimes  from  the  slackness, 


THE  HISTORY  AND  LITERATVUE  OF  SURGERY.  67 

otherwise  from  the  too  great  straightness  of  the  thred ;  sometimes  from 
its  sinalhiess,  cutting-  through,  or  from  its  weakness,  giving  way)  to  a 
new  flux  when  not  so  tolerable  to  the  Patient,  or  so  easily  cured  by  the 
Artist  as  at  first;  moreover,,  where  two  Vessels  or  more  bleed  in  one 
Wound  (whit'h  is  very  frequent),  the  one  must  be  neglected,  while  the 
Ligature  is  making  on  the  other."  But  he  says  :  "  The  ligation  of  an 
Artery  on  other  accounts,  as  in  the  Toothach,  Epiphora,  Aneurisma,  &c., 
is  not  hereby  impugned."  On  page  30  is  to  be  found,  perhaps,  the  first 
printed  description  of  a  tourniquet — "very  useful  in  iVmputations,  espe- 
cially above  the  knee  ;  that  is  to  say  a  wadd  of  hard  linnen  cloth,  or  the 
like,  inside  the  Thigh  a  little  below  the  Inr/iicn,  then  ])assing  a  Towel 
round  the  member ;  knit  the  ends  of  it  together,  and  with  a  Eattoon,  a 
Bedstalf,  or  the  like ;  twist  it,  till  it  compress  the  Wadd  or  Boulster  so 
very  strait  in  the  crural  vessels  that  (the  circulation  being  stopped  in 
them)  their  bleeding  when  divided  by  the  Excision,  shall  be  scarce  large 
enough  to  let  him  see  where  to  apply  his  Restrictives."  A  similar  tour- 
niquet had,  however,  been  used  l)y  John  Morell  in  1674  at  the  siege 
of  Besaiifon.  The  "  new  way  of  amputation  "  is  by  a  single  flap,  and 
is  the  first  printed  description  of  this  method,  which  he  says  he  learned 
from  Mr.  C.  D.  Lowdhara  of  Exeter. 

The  Complmt  Discourse  of  Wounds,  .  ...  as  also  a  Treatise  on 
Gunshot  Wounds  in  General,  by  John  Brown  (surgeon  to  the  king) 
(London,  1678,  4to),  is  a  pompous,  diffuse,  tedious  book,  containing 
nothing  of  any  impcu'tance. 

Some  curious  illustrations  of  the  English  surgery  of  the  middle  of 
the  seventeenth  century  are  to  be  found  in  the  Diary  of  the  Rev.  John 
Ward,  Hear  of  Strntford-upon-Avon,  extending  from  16^8  to  1679, 
edited  by  Charles  Severn  (London,  1839,  8vo).  For  example:  "A 
cancer  in  ]\Irs.  Townsend's  breast,  of  Alverston,  taken  off  by  two  sur- 
geons  First  they  cutt  the  skin  cross  and  laid  itt  Iwick,  then  they 

workt  their  hands  in  ytt,  one  above  and  the  other  below,  and  so  till 

their  hands  mett,  and  so  brought  itt  out There  came  out  a  gush 

of  a  great  quantitie  of  waterish  substance,  as  much  as  would  fill  a  flag- 
gon.  They  jiut  in  a  glass  of  wine  and  some  lint,  and  so  let  itt  alone 
till  the  next  day  ;  then  they  opened  itt  again,  and  injected  myrrhe,  aloes, 

and  such  things,  as  resisted  putrefaction,  and  so  bound  itt  up  againe 

The  way  how  and  where  itt  should  be  cutt  was  niarkt  with  ink  by  one 
Dr.  EdWards." 

"  Gill  told  mee  of  a  woman  that  had  an  apostheme  about  the  side, 
and  his  master  intended  to  trc])an  her  on  one  of  the  ribs ;  whether  it 
canne  be ; — I  suspected  itt  to  Ix'  a  ly." 

"  The  mountebank  that  cutt  wry  necks,  cutt  three  tendons  in  one 
child's  neck,  and  hee  did  itt  thus  ;  first  by  making  a  small  orifice  with 
his  launcet,  and  lifting  upp  the  tendon,  for  fear  of  the  jugular  veins, 
then  by  putting  in  his  incision  knife,  and  cutting  them  U])wards ;  they 
give  a  great  snaj)p  when  cutt.  The  orifice  of  his  wounds  are  small, 
and  scarce  any  blood  fiillows." 

"  Gill  said  Jiis  Mr.  Day  hath  amputated  five  armes,  three  leggs  and 
somewhat  else  since  he  came  to  Oxford,  and  but  two  of  all  these  died, 
and  one  was  a  person  of  sixty  years  att  least." 

"John  Phillips  his  child  had  a  red  swelling  in  the  forehead,  I  sup- 


68  THE  HISTORY  AM)  LITERATURE  OF  SURGERY. 

pose  ix  varix  or  nacvuss  and  itt  was  taken  off  In-  one  of  Coventry,  by 
tying  a  liair  ahont  itt,  and  oinlinii'  itt  liarder  everv  dav  ;  in  two  weeks 
itt  fotclit  itt  oif." 

A  curious  episode  in  the  history  of  surgery  in  the  iirst  ludf  of  the 
seventeenth  century  is  the  controversy  on  the  sympathetic  or  magnetic 
cure  of  wounds.  This  was  a  doctrine  of  Paraeeksus,  and  in  1(508  one 
of  his  foUovyers,  (ioclenius,  professor  of  medicine  at  ^larhurg,  called 
special  attention  to  it  by  iiis  \york,  Trdddtun  <Je  3I(ir/n<iica  Vuratione 
Vuliwrifi.  His  doctrines  were  objected  to  by  the  priests  on  religious 
grounds.  Van  Hehiiont  wrote  in  defence  of  the  doctrine,  and  liis  pam- 
phlet was  published  without  his  knowledge  in  1G21.  This  created  great 
excitement,  and  was  translated  into  English  by  Walter  Charleton,  and 
pul)lished  in  15(!0  under  the  title  ^1  ieniart/  of  Parciclo.rex.  The  cure 
was  to  anoint  the  bloody  sword  or  other  \ycaj)on  which  had  inflicted  the 
injury,  or  a  stone  or  cloth  dijiped  in  the  blood  as  it  flowed  from  the 
wound,  with  a  special  ointment,  and  put  it  away  carefully,  applying 
nothing  to  the  wound  but  a  bit  of  wet  lint.  Goclenius  thought  the 
cure  was  a  natural  process ;  the  priests  thought  it  was  due  to  magical 
formula  and  the  aid  of  the  devil  ;  and  Van  Helniont  tuidertook  to 
prove  that  both  were  wrong,  and  tliat  the  so-called  "  weapon  cure  "  was 
due  to  a  certain  mysterious  sympathy  precisely  analogous  to  what,  in 
later  times,  was  called  "animal  magnetism." 

The  priests'  view  that  weapon-salve  cures  are  magical  and  sinful  is 
given  in  the  Hoplocri.wiasponr/as  ;  or  a  sponge  to  unpe  away  the  weapon- 
sa/re,  by  AV'illiam  Foster,  Parson,  etc.  (London,  1 G31),  whicli  was  directed 
mainly  against  the  celebrated  Rosicrucian  Robert  Flndd,  who  replied  with 
Doctor  Fludds  answer  unto  M.  Foster,  or  the  squesing  of  Parson  Foster's 
sponge,  ....  wherein  the  sponge-bearer's  immodest  carriage  and  be- 
haviour towards  his  brethren  is  detected,  etc.  (London,  1631).  Fludd's 
book  is  much  better  reading  than  that  of  Foster. 

Sir  Kenehn  Digby's  discourse  at  IMontpellier,  on  the  cure  of  wounds 
by  the  jwwder  of  sympathy,  puldishcd  in  l(j57,  \yas  a  famous  book  in 
its  day.  A  less-known  Init  equally  curious  book,  by  C  de  Irvine,  an 
army  surgeon,  was  printed  at  Edinburgh  in  1656  under  the  title  of 
lledicina  Magnetica,  or  the  rare  and  wonderful  art  of  curing  by  sym- 
pathy, and  several  other  controversial  pamphlets  of  the  period  are 
noted  in  the  Index  Catalogue  of  the  Washington  Library  under  the 
heading  "  Symi)athy." 

After  the  expulsion  of  the  Moors  from  Spain  there  is  little  worth 
noting  in  the  history  of  sur'gery  in  that  country  until  after  the  middle 
of  the  sixteenth  century.  In  1488  it  was  ordered  that  those  wishing  to 
practise  surgery  must  be  examined  imder  the  direction  of  the  Brother- 
hood of  St.  Cosme  and  St.  Damian  at  Zaragoza,  to  which  association 
was  granted  the  privilege  of  dissecting  the  bodies  of  persons  dying  in 
the  hospital  recently  established  in  that  city.  The  surgeons  were  for- 
bidden to  order  or  to  dispense  internal  remedies.  At  the  end  of  the 
fifteenth  century  there  were  a  few  Spanish  \yriters  on  syphilis,  the  best 
known  being  Villalobos. 

The  first  celebrated  Spanish  surgeon  was  Francis  Arcfeus  (1493- 
157?),  whose  treatise,  De  recta  curandorinn  rulnerum,  ratione,  written 
in  his  old  age,  was  first  published  at   Antwerp  in  1574  and  again  at 


THE  HISTORY  AXD  LITERATURE  OF  SURGERY  69 

Amsterdam  in  1658.  This  was  translated  into  English  by  John  Eead, 
and  published  at  London  in  1588,  and  a  Dutoh  translation  was  published 
in  H)(i7.  Arcitus  recommends  the  use  of  the  tre])hine  in  fractures  of 
tile  skull,  describes  with  some  minuteness  the  operation  for  excision  of 
cancer  of  the  breast  and  an  apparatus  for  the  treatment  of  club-foot, 
and  advises  mercui-ial  inunctions  on  the  joints  for  syphilis.  His  treat- 
ment of  wounds  is,  in  the  main,  that  of  John  de  Vig<:). 

Another  Spanish  surgeon  of  the  sixteenth  century  of  some  repute 
was  Bartoleme  de  Aguero  (15;n-97),  professor  of  surgery  at  Seville, 
called  by  some  the  Spanish  Pare,  whose  works  were  published  in  1604 
uuiler  the  title  Tesoro  (k  la  verdadcra  cirujla,  and  in  other  editions  in 
1624  and  1654. 

Dionisio  Da^a  Chacon  (1510-159?),  a  surgeon  in  the  Spanish  army, 
.serving  in  many  countries  and  in  the  inuuediate  service  of  Charles  V., 
Phili])  II.,  Juan  of  Portugal,  Don  Carlos,  and  Don  John  of  Austria, 
wrote  his  Pradica  y  teorica  dc  cirujic  about  1580.  This  was  the  lirst 
comprehensive  work  in  surgeiy  written  in  Spanish.  He  used  the 
cautery  for  checking  hemorrhage  in  amputations,  did  not  consider  gun- 
shot wounds  poisonous,  and  abandoned  the  use  of  boiling  oil  in  treating 
them  after  1544,  at  the  suggestion  of  a  certain  M.  Bartolomeo,  proltably 
Maggius.  His  interesting  report  on  the  injury  of  the  head  of  Don 
Carlos,  in  which  he  opposed  \"esalius,  ^vho  advised  the  trepan,  is  given 
with  comments  bv  J.  M.  Guardia  in  the  Gazette  Med.  de  Paris,  1863, 
p.  41. 

Andreas  Alcazar,  professor  at  Salamanca,  published  in  1575,  in  folio, 
his  Chir>ur/iae,  ....  libri  sex,  and  in  1582  his  De  vidneribus  capitis. 

Juan  Fragosa,  surgeon  to  Philip  II.,  published  Erotemas  quirurgicos 
(Madrid,  1570,  4to),  De  la  Cirur/ia,  etc.  (Madrid,  1581,  fob),  Tratado 
de  cirtKjia  saeado  de  la  cirugia  unieersid,  a  little  manual  of  questions 
and  answers  for  students  (1692),  and  Cirujia  universal,  ....  Y  ma.^ 
otros  tres  tratados  ....  Una  summa  de  jyroposiciones  contraciertos 
avisos  de  cirugia  .  .  .  .  de  la^  deelaraciones  acerca  de  diversas  heridas 
y  muertos  .  .  .  .  de  los  AphorixmoK  de  Hi/ppoerates  tocantes  a  cirugia 
(Alcala,  1592,  and  several  later  editions). 

Cristobal  ]\Iontcmayor,  surgeon  of  Kings  Phili])  II.  and  III.,  wrote 
Medici nia  y  cirur/ia  de  rulnerihus  co^;///.s' (Valladolid,  1613;  Saragossa, 
1664). 

Pedro  Griigo  de  Vadillo,  a  .surgeon  of  Lima,  published  at  Madrid,  in 
1632,  Discursos  de  verdadera  cirugia  y  censura  de  ambar  vias,  y  eleccion 
de  1(1  primera  intcncion  curatira,  y  unicion  de  las  heridas,  of  which  a 
third  edition  appeared  in   1692. 

Eighteenth  Century. 

At  the  beginning  of  the  eighteenth  century  the  only  city  in  which 
there  were  any  special  o])portunities  for  the  study  of  surgery  was  Paris. 
There  was  no  place  for  the  barbers  or  the  barber  surgeons  in  the  univer- 
sities of  P^urope,  and  they  had  no  institutions  of  their  own  in  which  any 
teaching  worthy  of  the  name  could  be  obtained.  Many  of  them  had 
learned  something  in  the  camp  or  on  the  battle-field,  which  was  the 
great  practice  school  for  the  surgeons,  as  it  had  been  for  three  centuries, 


70  THE  HISTORY  AND  LITEUATURE  OF  SURGERY. 

and  there  were  hut  few  surgeons  of  the  time  in  Enghind,  I*' ranee,  or 
Germany  wlio  failed  to  gain  experience  therein.  Nevertheless,  this 
military  experience  contributed  little  to  the  advancement  of  surgery. 
Haeser  says  that  tlie  cliief  cause  of  tiie  supremacy  of  French  surgery  in 
the  seventeenth  and  eighteenth  centuries  was  the  wars  undertaken  by 
Louis  XIV.  and  his  successors,  and  that  streams  of  German  blood  con- 
tributed in  some  degree  to  the  foundation  of  the  mastt-i'ship  of  the 
French  in  tlie  <lomaiu  of  surgery.  There  is  a  grain  of  truth  in  this 
statement,  but  it  does  not  explain  why  the  German  and  the  English 
surgeons,  who  also  saw  more  than  enough  of  military  surgery  at  this 
period,  did  not  make  the  ssime  ])rogress  as  tlu;  French.  jVrmv  service 
gives  valuable  exjierieni-e  to  the  man  who  has  suitable  preliminary 
training  and  is  well  grounded  in  anatomy,  but  for  the  barbers  and  barber 
surgeons  of  the  eighteenth  century  such  service  increased  their  knowledge 
but  little.  It  is  true  that  the  surgeons  had  learned  something.  They 
knew  that  shot-wounds  were  not  poisonous  and  did  not  require  cauteriz- 
ing, and  a  large  number  of  them  probabl}-  also  knew  that  ordinary  wounds 
not  involving  the  bones  really  required  very  little  treatment.  Never- 
theless, they  kept  on  prescribing  and  using  their  oils,  ointments,  plasters, 
vulnerary  drinks,  etc.,  the  formula'  for  which  fill  a  considerable  space  in 
the  surgical  treatises  of  the  day  ;  and  there  is  one  special  reason  for  this 
which  the  modern  surgeon  and  historian  usually  does  not  fully  appreciate. 
This  reason  was,  that  the  charges  of  the  surgeons  in  those  times  were 
based  upon  these  ap])lications,  and  this  was  also  true  for  the  ordinary 
practitioners  of  medicine  :  they  compounded  and  dispensed  their  own 
remedies;  their  charges  were  nuulc  for  the  remedies  and  not  ibr  the 
visits ;  and  hence  the  fees  were  in  proportion  to  the  number  of  the 
mixtures,  draughts,  unguents,  etc.  which  were  ordered  for  a  particular 
case.  The  surgeons  at  the  beginning  of  the  eighteenth  century,  as  a 
rule,  used  styptic  powders  and  compression  to  check  hemorrhage.  Those 
who  knew  anything  about  the  use  of  the  ligature  apjjcar  to  have  been 
afraid  to  trust  it,  and  to  have  jireferred  the  actual  cautery.  It  was  sup- 
posed to  be  necessary,  or  at  all  events  desirable,  to  include  a  portion  of 
the  surrounding  tissues  with  the  artery  to  be  ligated,  for  fear  that  the 
ligature  might  cut  through  the  coats,  and  for  the  same  reason  the  cord 
was  often  tied  over  a  small  pad  instead  of  being  made  directly  to  encircle 
the  vessel.  In  the  army  the  surgeons  necessarily  practised  medicine,  but 
in  civil  life  they  were,  as  a  rule,  forbidden  to  use  or  prescribe  the  internal 
remedies,  that  being  the  business  of  the  physician,  who  claimed  exclusive 
rights  in  this  respect. 

Atthe  beginning  of  the  eighteenth  century  the  leading  surgeons  in  Paris 
were  Georges  Mareschal  (1(358-1736),  surgeon  of  tiie  Gharite  and  first  sur- 
geon of  Louis  XIV.  in  1703;  Jean  IMery  (1645-1722),  first  surgeon  of 
the  Hotel  Dieu  and  the  deviser  of  the  operation  of  suprapubic  puncture  of 
the  bladder;  and  Pierre  Dionis  (U)5?-1718),  who  had  commenced  teach- 
ing anatomy  at  the  Jardin  du  Roy  in  1673,  and  in  connection  with  his 
lessons  gave  demonstrations  of  surgical  operations  on  the  cadaver.  He 
had  many  pupils,  and  his  Couis  d'operations  de  Chirurgie,  first  published 
at  Paris  in  1707,  went  through  many  editions  and  was  translated  into 
English,  Dutch,  and  German,  being  a  popular  manual  for  fift}'  years. 
He  advises  the  ligature  of  arteries  in  amputations,  but  .says  that  at  the 


THE  HISTORY  AND  LITERATURE  OF  SURGERY.  71 

Hotel  Dieu  the  vitriol  button  is  used  instead.  He  advises  the  Marian 
operation  in  lithotomy,  but  says  that  he  does  not  believe  the  high  opera- 
tion to  be  so  dangeriius  as  is  supposed,  and  that  he  is  assured  tliat  AI. 
Bonnet  has  often  practised  this  operation  at  the  Hotel  Dieu  with  iiapjiy 
success.  He  tells  at  leugtli  tiie  story  of  Frere  Jacques  up  to  that  date, 
and  apparently  very  fairly,  showing  the  ignorance  of  the  man,  but  saying 
tiiat  a  surgeon  who  is  a  good  anatomist  may  succeed  by  his  method ;  Avhicli 
was  true  prophecy. 

This  Frere  Jacques — Jacques  de  Beaulieu  (1651-1719) — was  an 
ignorant  peasant  who  for  a  time  was  a  servant  of  an  Italian  Incisor 
named  Palloni.  He  became  a  monk,  or,  as  Dionis  says,  a  sort  of  a 
monk,  and  came  to  Paris  in  1697,  as  he  said,  to  show  the  surgeons  how 
to  perform  lithotomy  in  a  particular  way.  He  was  successful  at  first, 
and  acquired  great  reputation,  but  soon  had  many  deaths  and  left  Paris, 
going  ill  1704  to  Holland,  where  he  tauglit  his  method  to  Rau,  who 
improved  it  into  what  is  generally  known  as  the  lateral  operation. 
Frere  Jacques  himself  improved  iiis  methods  greatly  after  his  visit  to 
Paris,  and  spent  the  rest  of  his  life  as  a  wandering  lithotomist,  chiefly 
in  Austria  and  Italy. 

There  is  mucii  good  reading  in  Dionis  :  he  does  not  confine  himself 
to  a  mere  description  of  the  operations,  but  gives  anecdotes  which  furnish 
a  picture  of  his  times  and  surroundings. 

Gabriel  le  Cierc,  a  surgeon  of  Lille,  ]iublished  at  Paris  in  1092  a 
little  book  called  La  chirurgie  complete,  being  a  sort  of  quiz-coinpend 
with  questions  and  answers.  This  became  a  popular  manual,  passing 
througii  eighteen  editions  and  translations.  He  mentions  the  Hotel-Dieu 
method  of  stopping  l)leeding  arteries  by  vitriol  buttons,  and  says  that  it 
is  the  custom  of  the  Hotel  I)ieu  to  em])loy  a  ])erson  to  keep  on  the 
dressing  with  the  hand  for  twenty-fi)ur  hours  after  the  ojieration. 

B.  Haviard  (1656-1702),  surgeon  of  the  Hotel  Dieu,  published  in 
1702  iiis  Nouccau  vccn.eU  (V observations  chirurgieales,  which  was  trans- 
lated into  English  and  published  at  London  in  1740.  This  is  a  valuable 
collection  of  cases,  containing  a  description  of  the  tourniquet  (using  that 
name)  as  ap])lied  at  the  Hotel  Dieu  in  1688  in  a  case  of  successful  liga- 
tion of  the  femoral  for  a  wound  of  that  vessel.  He  refers  to  the  per- 
nicious atmosphere  of  the  Hotel  Dieu  and  its  eifects  on  wounds,  gives  an 
interesting  note  on  Frfere  Jacques,  describes  a  case  of  dermoid  cyst  of  tiie 
ovary  and  one  of  congenital  absence  of  the  penis,  and  gives  details  of 
some  remarkable  cases  of  litiiotomy.     It  is  a  book  worth  ha\'ing. 

Rene  Jacques  Croissant  de  Garengcot  (1 688-1759)  publislied  his  Trctite 
des  operations  <ie  chirurgie  in  1720  (2d  ed.,  3  vols.,  in  1731).  He  was 
one  of  the  best  anatomists  and  surgeons  of  his  time,  and  introduced 
many  methods  in  details  of  operations  for  nasal  polypus,  hare-lip,  stran- 
gulated hernia,  etc. 

Alexis  Littre  (1658-1726),  whoso  name  remains  connected  with  the 
form  of  hernia  first  described  by  him,  was  a  surgeon  who  devoted  him- 
self largely  to  pathological  anatomy,  and  wiiose  papers  are  contained  in 
the  Memoirs  of  the  Academy  of  Surgery.  He  first  proposed  the  opera- 
tion of  colotomy  in  1710. 

Nicolas  Andry  (1658-1742),  dean  of  the  medical  faculty  of  Paris  in 
1724,  is  known  in  the  history  of  surgery  by  his  U Orthopedic,  ou  Vart  de 


72  THE  JITSTORY  AND  LlTEllATVRE  OF  SURGERY. 

pvh-enif  et  de  corrir/cr  <1>i)is  /cs  niftinx  Irx  (llfforiiiiih  du  corps  (Paris,  ]  741), 
being  tlie  first  work  in  wiiicli  tiic  word  (irtlidpu'ilia  is  used.  It  is  a  ])i)j)- 
idar  treatise  on  the  eare  of  children,  and  has  very  little  to  do  with  oi-tlio- 
piedia  as  that  word  is  now  understood. 

The  most  distinguished  surgeon  of  the  first  half  of  the  eighteenth 
century  was  Jean  Louis  Petit  (1674-1750),  who  entered  the  army  at  the 
age  of  eighteen.  In  1700  he  settled  at  Paris  and  commeneed  giving  a 
private  eourse  of  lectures  in  anatomy  and  surgery.  He  invented  tiie 
screw  toui'niquet,  an  appliance  of  ahnost  as  nuicii  importance  as  tlie  liga- 
ture to  tlie  surgeon  who  iias  to  ani[)utate  with  unskilled  assistance,  devised 
herniotomy  without  opening  the  sac,  and  made  an  improvement  in  tiie 
circular  method  of  amputation  l)y  cutting  successively  the  skin  and  tiie 
muscles,  instead  of  dividing  them  at  (jne  stroke  according  to  the  old 
method.  This  was  carried  still  further  by  Desault,  who  divided  the 
muscles  on  two  levels.  To  Petit  also  is  due  the  credit  of  having  first 
demonstrated  the  mechanism  of  the  occlusion  of  arteries  in  wounds, 
showing  the  chief  process  to  be  the  formation  of  a  clot,  a  part  of  which 
surrounds  the  end  of  the  vessel  and  a  jiart  of  which  is  a  plug  oceujjying 
the  cavity  ;  and  of  giving  the  first  account  of  moUities  ossium. 

After  the  triumph  of  the  medical  faculty  over  the  surgeons  and  l)ar- 
ber  surgeons  in  tiie  middle  of  the  seventeenth  century,  the  College  of  St. 
Come  continued  to  give  instruction,  although  it  could  not  grant  degrees, 
and  in  1690  the  number  of  the  students  was  greater  than  the  number  of 
students  in  medicine,  being  over  seven  hundred.  It  was  by  no  means 
poor,  and  in  1691  it  began  the  construction  of  a  new  amphitheatre,  which 
was  completed  in  1694.'  In  it  were  given  lessons  on  anatomy  and  sur- 
gical operations,  and  similar  teaching  was  given  by  a  few  ambitious  young 
surgeons  as  a  private  enterprise.  To  lieconie  a  member  of  St.  Come  the 
aspirant  must  have  been  an  apprentice  for  at  least  six  years  before  he 
could  present  himself  to  perform  his  "  grand  chef  d'ceuvre,"  which,  if 
successful,  would  make  him  a  master  surgeon.  This  "grand  chef 
d'teuvre"  was  a  long  process  of  examination.  The  Washington  I^ibrary 
contains  a  manual  of  preparation  for  it,  in  the  form  of  a  neatly-written 
manuscript,  bound  in  four  volumes,  8vo,  "  par  C.  Caulay,  recu  chirurgien 
jure  le  24  judlet,  1737." 

Fran9ois  de  Lapeyronie  (1678-1747)  was  a  surgeon  of  Montpellier 
and  demonstrator  of  anatomy  in  the  School  of  Medicine.  He  came  to 
Paris  in  1714,  soon  became  surgeon  of  the  Charite,  and  first  surgeon  of 
the  king  in  1736.  He  was  wealthy,  and  spent  his  money  freely  for  the 
benefit  of  the  Royal  Academy  of  Surgery,  which  was  organized  in  1731, 
increasing  in  fame  and  jjrosperity  for  the  next  forty  years,  and  through 
the  agency  of  which,  to  a  considerable  extent,  Paris  became  the  great 
surgical  centi-e  of  the  world.  J.  L.  Petit  became  the  first  director  of 
theacademy,  and  Sauveur-Francois  Morand  (1697-1773)  its  first  secre- 
tary. Morand  was  an  ingenious  surgeon.  He  proposed  amputation  at 
the  hi])-joint  and  ovariotomy,  and  performed  the  high  o])eration  for 
stone,  but  he  was  an  uneducated  man,  and  Mas  unable  satisfactorily  to 
perform  the  duties  of  secretary  of  the  academy,  which  post  he  resigned 
in  1739.  He  was  succeeded'  by  Autoine  Louis  (1723-92),  to  Avhom 
the  success  of  the  academy  and  its  marked  influence  on  the  progress  of 
'  Corlieii :  La  France  Med.,  1878,  xxv.  p.  481. 


THE  HISTORY  AND  LITERATURE  OF  SURGERY.  73 

surgery  are  to  a  great  extent  due.  He  was  professor  of  physiology,  and 
in  1757  became  surgeon  of  tlie  Ciiarite,  l>ut  he  was  not  so  much  an 
•operator  or  inventor  as  he  was  a  learned  historian,  editor,  and  critie. 

An  indispensable  work  for  the  student  of  the  history  of  surgery  in 
France  at  this  period  is  the  collection  of  eulogies  pronounced  by  Louis 
upon  deceased  members  of  the  academy,  published  with  notes  and 
appendices  by  E.  F.  Dubois  in  1859.  These  so-called  Mo(/cs  are  judi- 
cial, critical,  historical  essays  whicli  are  unt'cpiallcd  in  surgical  luograjiiiy. 
.A.t  the  conuneucement  of  liis  eulogy  on  Le  Cat  lie  remarks  that  tiiese 
memoirs  will  form  a  part  of  the  liistory  of  the  ^^cademy  to  be  read  in 
years  to  come,  and  tliat  the  truth  must  be  told  ;  and  in  this  he  was  a 
true  prophet.    His  (EVcre.s  diccrM's  de  chlrurgic  were  published  in  1788. 

Of  the  earlier  members  of  the  academy,  besides  those  already  named, 
the  most  distinguisiied  were  Le  Dran  and  Le  Cat.  Henry  Fran9ois  le 
Dran  (1685-1773),  the  son  of  a  surgeon,  was  educated  in  Paris,  and 
became  a  master  in  surgery  at  the  age  of  twenty-two.  In  1724  he  was 
appointed  one  of  the  four  surgeons  of  the  Charite,  and  established  an 
anatomical  school  there,  and  in  1730  published  his  Parallele  des  diffe- 
rentf'K  mnni^re  de  tirer  la  pierre  hors  de  la  vessie,  which  gaye  him  much 
reputation.  In  1734  he  was  sent  as  chief  surgeon  to  the  army,  and  pub- 
lished the  result  of  his  obseryatious  in  1737  in  his  Traitc  ....  ■mr  Ics 
j)l(ii/cn  d'armcft  a  feu,  which  went  througii  several  editions.  In  1742  he 
j)ublishcd  a  treatise  on  operative  surgery.  Le  Dran  made  no  great  con- 
tribution to  surgery,  but  he  was  a  celebrated  teacher  and  had  many 
])upils  from  Germany,  through  whom  his  method  became  popular  in 
that  country. 

Claude  Nicolas  le  Cat  (1700-68)  was  a  surgeon  of  Rouen,  wiio 
l)ei'ame  surgeon-in-chief  of  tlie  Hotel  Dieu  of  that  city  as  the  result 
of  concoiu's  in  1729.  He  won  many  prizes  from  the  Academy  of  Sur- 
gery in  Paris,  being  specially  skilled  in  "  prize-essay  writing,"  became 
professor  of  anatomy  and  surgery  in  the  school  established  at  Rouen  in 
1736,  and  attracted  many  students.  He  was  a  voluminous  ^vriter,  l)ut 
his  papers  wiiich  relate  to  litiiotomy  are  tiie  only  ones  of  any  special 
A'alue.     His  rejnitation  was  greater  abroad  than  it  \vas  at  home. 

Otlier  surgical  writers  of  this  period  are  (Tuillanmc  Mauquest  de  la 
Motte  (1655-1737),  whose  Trade  complet  de  chirurr/ie  (3  vols.,  Paris,  1 722) 
was  a  very  popular  text-book  ;  Georges  de  la  Faye  (1699-1781),  whose 
Priiicipes  de  rhirure/ie  (Paris,  1739),  an  elementary  handbook,  passed 
through  many  editions  and  translations;  and  Elie  Col  de  Villars  (1675- 
1747),  whose  ('ours  de  ehirun/ie  a])peared  in  173.S. 

Dominicjue  Anel  (1678-1725  ?),  a  native  of  Toulouse,  was  a  pupil  of 
J.  L.  Petit,  a  surgeon  in  the  French  and  Austrian  armies,  and  a  wan- 
derer over  Europe.  In  1710  he  ligated  the  brachial  artery  of  a  priest 
in  Rome  for  traumatic  aneurism,  and  tliis  is  claimed  as  a  triumph  of 
Frencli  surgery  preceding  the  metiiod  of  John  Hunter.  In  fict,  it  was 
tiie  operation  performed  and  dcscril)ed  long  bef  )re  by  Guillemeau.  In 
Genoa,  in  1712,  he  devised  his  operation  for  lachrymal  fistula  and  the 
syringe  \vhich  still  bears  his  name.  In  1716  he  was  practising  as  an 
eye  surgeon  in  Paris. 

George  Arnaud  de  Ronsil,  a  French  surgeon,  went  to  London  prior 
to  1748,  and  remained  there  until  his  deatii  in  1774.     His  Dissertation 


74  THE  HISTORY  AND  LITEUATUBE  OF  SURGERY. 

on  Hernia  (London,  1748)  was  a  ])a))t'r  of  niiioli  importance.  His 
Memoires  de  chirurf/le  (London,  1702,  2  vols.  4to)  cdntains  matter  of 
permanent  value,  and  a  curious  paper,  "  Inconveniens  des  Descentes  par- 
ticuliers  aux  Pretres  de  l'£glise  Komaine,"  with  reference  to  Leviticus 
xxi.  20.  In  1732  he  excised  the  caecum  and  a  part  of  the  colon  and 
ileum  in  a  case  of  hernia. 

Jean  Baseilhac  (1703-81),  better  known  as  Frere  Come,  was  the  son 
of  a  surt;eon  and  was  educated  as  such.  In  1729  he  became  a  monk, 
but  continued  to  practise  surgery  among  the  poor,  and  invented  the 
lithotome  cache.  He  published  anonymously  in  1751  an  account  of 
his  operation,  and  in  1779  published  a  paper  on  the  high  operation. 
He  was  a  skilful  surgeon,  and  obtained  greater  success  with  his  instru- 
ment than  any  other  person  has  been  able  to  do. 

Pierre  Brasdor  (1721-97)  was  professor  of  anatomy  and  operative 
surgery  in  the  College  of  Surgeons  of  Paris,  and  contril)uted  to  the 
Memoirs  of  the  Academy  of  Surgery.  His  name  is  remembered  in  con- 
nection with  his  suggestion  to  treat  certain  aneurisms  by  ligation  of  the 
artery  on  the  distal  side  of  the  tumor  ;  which  was  first  done  by  Wardrop. 

Francis  G.  Ijcvacher  published  in  the  Memoirs  of  the  Academy  of 
Surgery,  in  17(j9,  a  paper  on  gunshot  wounds,  in  which  lie,  for  the  tirst 
time,  showed  that  what  were  sujiposed  to  be  the  effects  of  the  wind  of  a 
ball  were  really  due  to  the  ball  itself. 

Hugues  Ravaton,  a  surgeon  of  the  French  army,  published  in  1750 
the  best  treatise  on  gunshot  wounds  which  had  yet  appeared.  His 
Chinirgie  rVarm^e  was  issued  in  17(j7,  and  his  Pratique  moderne  de  la 
ehintrgie  in  1770.  He  was  the  first  to  practise  amputation  by  the 
double-flap  method. 

Jean  Joseph  Sue  (1710-92),  son  of  a  Paris  surgeon,  and  often  men- 
tioned as  "Sue  le  jeune,"  was  a  teacher  of  anatomy,  and  in  1761  one  of 
the  surgeons  of  the  Charite.  He  published  £lemenh  de  chirurgie  (Paris, 
1755),  Traite  des  bandages  (Paris,  1761),  and  Dictionnaire  posifif  de 
chirurgie  (Paris,  1779). 

Jean  Louis  Belloq  (1730-1807),  a  professor  of  anatomy  in  Paris, 
devised  a  number  of  instruments,  among  which  was  the  canula  for 
plugging  the  posterior  nares  still  known  by  his  name. 

In  the  latter  part  of  the  century  the  leading  surgeon  in  Paris  was 
Pierre  Joseph  Desault  (1744-95),  who  became  surgeon  of  the  Hotel 
Dieu  in  1788,  and  soon  had  a  crowd  of  students  following  his  public 
clinic,  the  like  of  which  had  never  been  seen  before.  He  was  a  pupil 
of  Louis  and  of  Morand,  and  surgeon  of  the  Charite  in  1782.  He 
■was  the  first  teacher  of  surgical  anatomy  in  the  modern  sense  of  the 
term,  made  many  improvements  in  the  treatment  of  fractures,  and  con- 
tributed largely  to  the  perfecting  of  surgical  technique.  He  wrote 
almost  nothing,  but  his  pupil,  Bichat,  gave  the  substance  of  his  teach- 
ings in  the  CEuvres  chirurgimles  (3  vols.,  1798-1803).  In  1792,  Desault 
was  arrested  on  the  charge  of  having  poisoned  the  wounds  of  some  of  the 
revolutionists  who  had  been  brought  to  the  Hotel  Dieu.  It  was  then  but 
a  step  from  the  prison  to  the  scaffold,  and  his  pupils  formed  themselves 
into  a  deputation  to  defend  him  before  the  tribunal,  their  spokesman 
being  Jean  Pierre  Maunoir,  a  young  Swiss,  afterward  a  celebrated  sur- 
geon in  Geneva,  whose  pleadings  prevailed  and  Desault  was  released. 


THE  HISTORY  AND  LITERATURE  OF  SURGERY.  75 

The  Hotel  Dieu  of  Paris  was  the  "  oldest,  largest,  richest,  and  worst 
hospital  in  Europe."  In  the  latter  part  of  the  eighteenth  century  it  con- 
tained over  twelve  hundred  l>eds,  and  sometimes  over  three  thousand 
patients,  having  four  or  five  in  one  bed.  The  first  distinct  mention  of 
surgeons  in  the  Hotel  Dieu  occurs  in  the  records  of  the  year  1539,  in 
which  it  is  ordex-ed  that  the  surgeon  Jocot  la  Normand  shall  be  retained 
to  serve  as  surgeon  in  the  Hotel  Dieu  in  place  of  George  Barbas  at  a 
salary  of  about  one  hunilred  antl  eighty  francs.  By  declai'ation  of  the 
managers  in  1(505  the  surgeon  nuist  call  a  physician  to  see  all  the  opera- 
tions of  surgery  which  he  shall  make  witliin  the  Hotel  Dieu. 

In  165-1,  Jacques  Petit,  master  of  surgery  in  Paris,  was  named  sur- 
geon of  the  Hotel  Dieu.  This  was  an  invasion,  for  up  to  that  time  the 
surgeons  had  been  chosen  from  among  tlie  surgeons  of  the  hospital. 
This  Jacques  Petit  gave  a  course  of  anatomy  to  the  pupils  in  the  hos- 
pital, commenced  the  collection  of  instruments  of  surgery,  and  gave  a 
sort  of  course  of  surgery  at  the  liedside.  Tliis  was  tiie  beginning  of 
clinical  surgery  in  this  hospital  and  in  France.  He  entered  the  hotel 
at  the  age  of  thirteen,  studied  sui'gery  there,  and  filled  the  place  of  sur- 
geon-in-chief until  1705.  The  story  was  that  he  was  more  than  sixty 
years  in  the  house  without  putting  his  foot  outside  of  it. 

He  was  succeeded  in  1 705  by  Mery,  one  of  the  most  celebrated  of 
the  surgeons  of  this  period.  Mery  was  succeeded  in  1722  by  Thibault, 
he  by  Pierre  Boudou,  and  he  by  Moreau,  who  was  succeeded  by  Desault 
in  1786.     Desault  was  succeeded  by  Pelletan  in  1795. 

The  records  of  the  Hotel  Dieu  which  escaped  the  fire  of  1871  have 
been  published  by  the  Bureau  of  Public  Assistance  under  the  title  Col- 
lection ill'  ilocHincnis  pour  acvrir  <),  I'hixfoire  des  hopitaii.v  de  Paris  (Paris, 
18S1-S7).  In  the  second  of  these  volumes,  pul)lished  in  1883,  are  given 
the  deliberations  of  the  governors  of  this  hospital  for  the  years  1768  to 
1791,  at  the  time  when  the  hospital  was  badly  overcrowded  and  com- 
plaints were  being  made  by  the  surgeons  of  the  management  of  the 
institution.  Among  other  things,  it  contains  a  copy  of  the  memoir  of 
the  Sisters  in  charge  of  the  hospital,  who  in  1 789  made  a  complaint 
against  Desault  to  the  effect  that  he  was  bringing  pupils  from  tiie  out- 
side into  the  amphitheatre,  which  should  be  reserved  for  the  pupils  of 
the  hospital  alone,  that  the  dressing  of  wounds  was  being  interfered 
with,  and  that  from  two  to  three  hundred  strangers  were  admitted  every 
day  to  hear  iiis  lectures.  To  this  there  is  a  long  reply  by  Desault,  show- 
ing that  tlie  complaints  were  in  part  ill  founded,  and  urging  that  it  is 
contrary  to  the  public  good  to  confine  clinical  instruction  to  the  pu))ils 
resident  in  the  house.  The  matter  was  investigated  and  the  decision 
was  given  in  favor  of  Desault.  A  very  interesting  description  of  the 
old  Hotel  Dieu,  showing  the  arrangement  and  character  of  the  beds  and 
furniture,  overcrowding,  etc.,  is  given  by  Dr.  J.  B.  Tenon  (1724-1816) 
in  his  Mciiwires  stir  les  hopitau.v  dc  Pari.i  (1788,  4to). 

Francois  Chopart  (1743-95)  became  professor  in  1771,  and  in  1780 
published,  with  Desault,  the  Traite  de.s  maladies  chirurgicales  et  des 
operations,  etc.,  which  contains  some  of  Desault's  views,  but  which  was 
wholly  written  by  Chopart.  His  name  remains  connected  with  a  form 
of  partial  amputation  of  the  foot  first  described  in  1792. 

Raphael  Bicnvenu  Sabatier  (1732-1811)  was  a  pupil  of  Petit,  and 


76  THE  HISTOllY  AM)  LITERATURE  OF  SURGERY. 

hceanie  professor  of  anatomy  in  the  Royal  College  of  Surgery.  His 
princi])al   work  was  his  Dc  hi  m/'rhrinc  ojjeratoire  (ti  voh.,  1  7!).S-1S10). 

J.  Fr.  l>('S('hanip.'<  ( 1740-1X24),  a  ])M|)il  of  Moreau  and  surgeon  of 
till'  diarite,  l)rought  tiie  Hunterian  ojteration  for  aneurism  into  notiee 
in  France,  and  published  an  interesting  historical  treatise  on  lithotomy 
in  1796. 

Francois  Quesnay  (l(;fl4-1774),  secretary  of  the  Academy  of  Surgery, 
wrote  a  work  on  the  iiistorv  of  surgery  in  I'^'auce  wliich  is  full  of  errors. 

Antoine  Portal  (1742-18;52),  professor  of  anatomy  in  the  Royal  Col- 
lege of  France,  is  the  author  of  Hidoire  dc  P  anntomie  et  de  la  chirurgie, 
etc.  (7  vols.,  Paris,  177()-7o),  which  is  a  useful  book  of  reference. 

Jean  Rene  Sigault  studied  surgery  at  Paris,  and  was  received  as  mas- 
ter in  the  school  in  1770.  In  1768  he  presented  a  memoir  to  the  Royal 
Academy  of  Surgery  proposing  to  substitute  the  section  of  the  symphysis 
of  tiie  pubis  for  the  Ctesarian  section.  The  proposal  was  not  aj)j)roved, 
but  he  performed  the  operation  in  1777  with  success,  and,  as  he  had 
become  a  doctor  of  the  Faculty  of  Medicine,  his  new  operation  was 
received  with  great  enthusiasm  by  the  members  of  the  faculty.  He 
])ublislied  his  Memoire  [xur  la  section  de  la  sipnphyse  des  os  pubis, 
pratiqia'c  sur  la  femme  Soiu-hot'\,  lu  aii.r  assemblees  dii  3  d  du  6  decembre, 
1777  (16  pp.  4to,  Paris,  1777),  and  Discours  sur  les  avanfar/cs  de  la 
section  de  la  symj^lujse  (8vo,  Paris,  1778). 

Georg  Fischer,  in  his  Chirurgie  vor  100  Jahrcn  (Leipzig,  1876),  has 
given  a  graphic  picture  of  the  condition  of  surgery  and  surgeons  in 
Germany  in  the  eighteenth  century.  The  great  mass  of  the  ]>eople 
<H)nld  only  obtain  surgical  treatment  from  local  liarbers  or  from  wander- 
ing charlatans.  The  barber's  apprentice  could  hardly  write  or  even 
read  German.  He  learned  how  to  shave,  and  then  ^\•ent  from  house 
to  house  to  serve  his  master's  clients.  He  was  also  taught  how  to 
sharpen  knives,  sjiread  blisters,  and  make  lint.  He  performed  the  most 
menial  duties  in  the  house,  and  occasionally  one  of  the  unhappy  youths 
ran  away  and  was  duly  advertised  as  a  sort  of  runa\\ay  slave.  The 
people  were  grossly  ignorant  and  intensely  superstitious,  lielieving  in 
charms  and  magic ;  and  the  supply  of  this  kind  of  medicine  was  not 
wanting.  The  cutters  for  stone  and  hernia,  the  cataract-operators,  the 
bone-setters,  and  the  travelling  charlatans  flourished  everywhere,  and 
the  repeated  edicts  and  ordinances  issued  by  kings,  nol)les,  and  city 
autiiorities  to  remove  the  complaints  made  by  the  physicians  and  to  settle 
the  ditticulties  merely  prove  the  condition  of  the  times  and  seem  to  have 
had  very  little  etfect.  Even  the  executioners  competed  witli  the  sur- 
geons. They  were  supposed  to  have  special  dealings  with  the  powers 
of  evil,  and  in  consequence  to  have  special  knowledge  of  the  means  of 
curing  diseases  considereil  to  be  due  to  witchcraft.  A  part  of  their  busi- 
ness was  to  dislocate  joints  l)y  the  rack  or  to  break  bones  ujxm  the  wheel, 
and  hence  it  was  supposed  that  they  had  special  skill  in  the  repair  of 
fractures  or  of  dislocations. 

The  practice  of  medicine  was  forbidden  to  the  executioners  in  Prussia, 
but  in  the  year  1744  Frederick  the  Great  granted  to  them  permission  to 
treat  fractures,  wounds,  and  ulcers,  and  \\\\q\\  the  Berlin  surgeons  com- 
plained of  this  he  issued  an  order  saying  that  he  had  not  ]>ermitted  all 
executioners,  Init  only  the  skilful  ones,  to  practise,  and  if  tlie  surgeons 


THE  HISTORY  AND  LITERATURE  OF  SURGERY.  77 

are  as  skilful  as  they  pretend  to  be,  every  one  will  rather  trust  them  than 
go  to  an  executioner ;  but  if  the  surgeons  are  ignoramuses,  the  public 
must  not  sutfer,  but  must  submit  to  be  treated  by  the  executioner  rather 
than  to  remain  lame  and  crippled. 

In  Germany  the  first  surgeon  of  importance  in  the  eighteenth  century 
was  Lorenz  Heister  (1683-1758),  a  native  of  P'rankfort-on-the-Maiu. 
After  studying  medicine  for  four  years  at  Giesseu  and  other  German 
universities,  he  went  to  Amsterdam  in  1706  to  study  anatomy  and  sur- 
gery under  Ruysch  and  Ran,  and  took  his  degree  at  Leydcn  in  1708. 
He  gained  experience  in  the  army  hos])itals  at  Brabant  and  Flanders, 
made  a  tour  into  Great  Britain,  and  in  1710  became  professor  of  anatomy 
and  surgery  in  tiie  University  of  Altdorf  Here  he  lectured  in  Latin,  l)ut 
found  the  students  and  young  surgeons  so  ignorant  that  he  determined  to 
print  his  system  of  surgery  first  in  German,  which  he  did  at  Nuremberg 
in  1718,  as  he  states  in  his  preface  to  later  editions,  and  as  given  in  bibli- 
ographies. I  have,  however,  never  been  able  to  see  a  copy  of  this  date, 
the  earliest  edition  in  the  Washington  Library  having  the  imprint "  Niirn- 
berg,  bey  .loluuin  Hoffmanns  seel.  Erbeu,  im  Jahr  nidcexix."  The  work 
was  a  very  ])i)pular  one,  and  M'as  translated  into  Latin,  and  thence  into 
English  under  the  title  of  A  general  Hystem  of  surgery  (1743;  7th  ed. 
1759),  forming  a  thick  quarto  which  is  still  excellent  reading  for  a 
surgeon.  Sharp  saj^s,  in  the  preface  of  his  Critical  enquiry  (1750), 
"  Heister's  Surgery  is  in  every  body's  hands,  and  the  character  of 
Heister  is  so  well  established  in  England,  that  any  account  of  that 
work  is  needless." 

The  other  German  university  professors  of  surgery  in  the  first  half 
of  the  eighteenth  century  who  are  worthy  of  note  are  Haller,  Platner, 
Mauchart,  and  Bass. 

xVlbrecht  von  Haller  (1708-77),  a  native  of  Bern,  a  pupil  of  Boer- 
haave,  and  one  of  the  greatest  physicians  wlio  ever  lived,  was  professor 
of  anatomy  and  surger}'  in  the  University  of  Gottingen  from  17.36  to 
1753,  and  exerted  a  powerful  influence  on  the  development  of  anatomy, 
jihysiology,  and  surgery  through  his  \vritings  and  his  pupils,  who  came 
to  him  from  all  parts  of  Europe.  He  never  performed  a  surgical  opera- 
tion on  the  living  body,  and  his  teaching  in  stu'gery  was  therefore  purely 
theoretical.  His  Bihliofbcca  chirurgica  (2  vols.,  Berne,  1774-75)  is  the 
most  valual)le  work  on  the  history  and  literature  of  surgery  that  has  ever 
been  published.  He  placed  on  a  firm  foundation  the  experimental  method 
in  dealing  with  surgical  problems  wdiich  was  a  little  later  so  successfully 
employed  by  .Tohu  Hunter,  and  which  has  contributed  so  much  to  our 
kno\vle(lge  during  the  present  century. 

Johann  Zacharias  Platner  (l()!t4-1747)  was  ])rofessor  of  auatomv  and 
surgery  in  the  University  of  Leipzig  from  1724  until  his  death.  His 
Iniiiitutiones  chirurgice  rationales  turn  medica',  etc.  (Leipzig,  1745)  jiassed 
through  several  editions  and  was  trn-islatcd  into  German  and  Dutch. 

Burchard  David  Mauchart  (1696-1 751)  studied  at  Tiibingen,  Altdorf, 
and  Paris,  and  became  professor  of  auatoiuv  and  surgcrv  in  the  Univer- 
sity of  Tiibingen  in  1726.  He  devoted  himself  chiefly  to  the  anatomy 
and  diseases  of  the  eye,  and  left  no  systematic  treatise,  but  published  a 
nund)er  of  dissertations,  which  were  collected  after  his  death  and  pub- 
lished in  three  volumes  (Tubingen,  1783-86). 


78  THE  IIISTORY  AND  LITERATURE  OE  SUROERY. 

Hi'inric'li  Bass  (1670-1754)  bccamo  professor  of  surgery  in  the  Uni- 
versity of  Halle  in  1718,  and  in  1720  ])ul)lislK'(l  his  (irihullirlier  Bfrivht 
von  Ji<iii(1ii</('ii,  which  was  a  favorite  text-hook  for  the  next  fifty  years. 

The  <;reat  ditht'iilty  experieneed  liy  the  trovernnient  in  providinfr 
eom])etent  surgeons  for  the  troops  led  to  tiie  organization  in  1724,  at 
lierlin,  of  a  niedieo-ehirurgical  college,  the  Friedrieh  Wilhelnis  Institut. 
In  1727  the  Charite  Hospital  was  fonnded  by  King  Friedrieh  Wilhelni  I., 
mainly  to  furnish  clinical  instruction  to  the  students  of  this  college.  The 
supply,  however,  was  not  equal  to  the  demand,  for  Frederick  11.  in  his 
Silesian  campaigns  found  an  urgent  need  for  skilled  surgeons,  and  sent 
some  of  his  young  officers  to  Paris  and  Strasburg  to  perfect  tlieir  educa- 
tion and  to  fit  themselves  to  instruct  others,  and  in  1743  he  engaged 
twelve  French  surgeons  and  assistants  for  the  benefit  of  his  troops.  The 
results  were  not  altogether  satisfactory,  because  surgery  M'as  generally 
considered  to  be  distinct  from  and  inferior  to  medicine ;  those  who  were 
destined  to  it  were  usually  apprenticed  to  barbers,  and  the  young  sur- 
geons were,  as  a  rule,  men  of  an  inferior  class  and  of  little  education. 
Finally,  in  1795,  as  the  result  of  urgent  appeals  from  Gorcke,  the  sur- 
geon-general of  the  Prussian  army,  the  college  was  reorganized  under 
the  name  of  the  Pe]>iniere,  and  was  devoted  exclusively  to  the  education 
of  medical  offic'ers  for  the  army,  retaining  a  special  connection  with  the 
Charite.'  An  institution  similar  to  the  Pepiniere,  and  for  the  same  pur- 
pose, was  organized  in  Dresden  in  1748  as  the  "Collegium  Medico- 
chirurgicum."  - 

The  three  German  military  surgeons  of  chief  repute  during  this  period 
were  Schmuckor,  Bilguer,  and  Theden. 

Johann  Lebrecht  Schmucker  (1712-86)  was  educated  at  the  Pepiniere, 
and  sent  to  Paris  for  two  years  by  the  king  to  study  under  Le  Dran. 
He  became  the  surgeon-general  of  the  army,  and  pnljlished  the  results 
of  his  experience  in  his  Chirurgischc  Wahntchmungcn  (2  parts,  1774) 
and  Vermisohte  chirurgische  Schriften  (3  vols.,  Berlin,  1776-82).  His 
observations  on  wounds  of  the  head  and  trephining  and  on  amputations 
are  the  most  valuable  of  his  writings. 

Joh.  Ulrich  Bilguer  (1720-96)  studied  at  Strasburg  and  Paris,  and 
entered  the  army  in  1741.  In  1757  he  became  the  second  surgeon- 
general.  In  1761  he  published  his />(■  mernhrorum  ampufatione  rarissime 
administranda,  etc.,  which  passed  through  numerous  editions.  In  this  he 
opposed  the  excessive  tendency  to  amputation  of  his  time,  which  was 
rather  encouraged  by  Schmucker,  and  went  to  the  other  extreme.  His 
Chinirglsche  Wahrnehinungrn  (Berlin,  1763;  translated  into  English, 
London,  1764)  is  his  most  important  work. 

Joh.  Christ.  Anton  Theden  (1714-97)  was  educated  as  a  barber  sur- 
geon, entered  the  army  in  1737,  and  became  third  surgeon-general  in 
1758  and  first  surgeon-general  in  1786.  His  Neue  Bemerkungen  mid 
Erfahrungen  zur  Bcrcichcriing  der  Wundarzneykunst  mid  3Icdicin  (pub- 
lished in  1771  and  later  editions,  also  in  a  French  translation)  contains 
accounts  of  some  remarkable  cases  and  surgical  methods — so  remarkable, 

'  For  details  consult  Das  Konigl.  preus.  Med.-chir.  Friedrieh  Wilhdms  Institut,  von  D. 
E.  Prenss,  Berlin,  1819,  8vo. 

'  For  the  history  oi^  this  see  Das  Kom'glich  scichsische  Collegium  Medieo-chirurgicmn,  von 
Dr.  H.  Fr51ich,  im  Der  Feklarzt,  AVien,  1877,  No.  9. 


THE  HISTORY  AND  LITERATURE  OF  SirROERY.  79 

in  fact,  as  to  excite  some  suspicion.  For  tlie  ligature  of  arteries  in  am- 
putation he  substituted  graduated  compresses  and  tiie  use  of  a  certain 
wonderful  lotion,  the  "  arquebusade,"  composed  of  vinegar,  alcohol,  sugar, 
and  dilute  sulphuric  acid,  with  some  salt  of  lead.  He  strongly  advocated 
methodical  bandaging  of  the  extremities,  claiming  by  its  use  to  have 
cured  aneurism,  varix,  etc' 

In  the  last  half  of  the  century  the  two  chief  German  surgeons  were 
Von  Siel)old  and  Richter. 

Carl  Casper  von  Siebold  (1736-1807),  the  son  and  apprentice  of  a 
surgeon,  served  for  a  time  in  French  hospitals,  and  studied  in  Paris 
under  Morand  and  in  I^ondon  under  Pott  and  Bromfield.  In  1769  lie 
became  professor  of  anatomy,  surgery,  and  obstetrics  at  AViirzljurg,  and 
soon  acquired  great  reputation  as  an  operator  and  clinical  teacher.  He 
was  succeeded  as  professor  and  as  surgeon  of  the  Julian  Hospital  by  his 
son.  Job.  Barth.  Siebold  (1774-1814),  who  founded  a  journal  called 
Chiron,  devoted  to  surgery. 

August  Gottlieb  Richter  (1742-1812)  became  professor  of  surgery  in 
Gottingen  in  1766,  and  gave  a  new  impulse  to  the  study  of  that  art  in 
Germany,  l)eing  the  tirst  to  jilace  it  on  a  scientific  basis.  He  was  the 
best  teacher  of  surgery  in  Germany  in  his  day,  had  travelled  extensively, 
was  familiar  with  the  good  work  then  going  on  in  France  and  England, 
and  was  an  excellent  writer.  His  Ahhandhmg  von  den  Bruehcn 
(1777-79)  was  the  best  book  on  hernia  up  to  that  date,  and  is  still 
a  classic.  His  history  of  surgery,  Anfaiu/.'^;/ri'in<1e  den  WundarzncifkiDist 
(7  vols.,  1782-1804),  is  a  model  in  arrangement  and  style,  but  is  not 
complete.  His  journal,  the  Chirurgische  Bibliothck  (15  vols.,  1771-96), 
did  more  to  develop  surgery  in  Germany  than  any  previous  agency. 

In  Austria  there  is  little  worthy  of  note  in  the  history  of  surgery 
until  the  latter  part  of  the  century.  Gerard  van  Swieten  (1700-72),  a 
pui>il  and  friend  of  Boerhaave,  went  to  Vienna  in  1745  and  introduced 
clinical  instruction,  but  the  only  surgeon  of  repute  there  in  1780  was 
Ferdinand  von  Leber,  who  is  principally  known  by  the  investigation 
which  he  made  upon  the  use  of  torture  in  jurisi)rudenee.  In  1785  the 
Military  Medico-Chirurgical  Akademie  was  founded  by  the  emperor 
Joseph  II.  and  placed  under  the  direction  of  Brambilla,  the  object  being 
the  «nne  as  that  of  tlie  Berlin  Pepiniere.  It  was  connected  with  a  hos- 
pital of  twelve  hundred  Ix'ds,  and  received  one  hundred  pupils,  of  whom 
twenty-four  were  residents  in  the  house.  The  course  of  study  was  two 
years,  and  after  passing  the  examination  the  student  received  the  degree 
of  doctor  in  surgery  and  the  first  vacant  position  in  a  regiment. 

Giovanni  Alessandro  Brambilla  (1728-1800)  was  an  Italian  who  had 
studied  in  Pavia,  and  liecame  a  surgeon  in  the  Austrian  army  and  a  special 
favorite  of  the  emperor.  He  pi-epared  the  Insfnikiion  fur  die  Profes- 
soren  der  k.  h.  chirurf/isriioi  Militurakademie  (Wien,  1784,  4to)  and  the 
Instrukfiun  fur  das  k.  k.  Jlilitdrnpital  zu  Wicn  (Wien,  1784,  4to),  which 
are  curiosities  in  literature.  The  subjects  and  the  order  of  the  subjects 
to  be  taught  are  scheduled  for  each  professor.  He  also  published  a 
large  atlas  of  engravings  of  surgical  instruments  and  a  history  of  dis- 
coveries made  by  Italian  anatomists  and  physicians,  and  exerted  a  power- 

'  For  details  as  to  the  military  surgery  of  these  times  see  Die  Krieys-Chiruryie  der 
letzcn  ISO  Jahre  in  Preussen,  von  Dr.  E.  Gurft,  Berlin,  1876. 


80  THE  JirSTORY  AND  LITERATURE  OF  SURGERY. 

fill  iiillucncc  upon  tlic  j)i'()trress  of  surfriciil  education,  ;iltli()ii;;li  ho  made 
no  special  imj)rovenients  himself.  A  proteg6  of  Branil)illa  was  Joh. 
Nejionuik  Ilunezovsky  (1752-98),  a  barber's  apprentice,  who  in  1781 
was  ap])(>inted  professor  in  the  military  medical  school  at  (iumpendorf, 
and  published  a  compendium  of  surgical  operations  in  178'),  of  which 
there  were  three  later  editions. 

iVt  the  commencement  of  the  eiffhteenth  century  Holland  was  a  great 
centre  of  medical  instruction  :  Boerhaave  had  introduced  clinical  teach- 
ing at  Leyden,  where  Bidloo  was  also  lecturing ;  Ruysch  and  Rau  were 
teaching  in  Amsterdam,  and  all  who  desired  a  complete  education  in 
surgery  visited  these  schools. 

Frederik  Ruysch  (Ki.'^iS-l  731 )  commi'nceil  teaching  anatomy  in  Ley- 
den in  l()(j(),  and  became  famous  for  the  jicrfection  of  his  anatomical 
preparations,  and  especially  for  his  injected  prejiarations.  His  collection 
was  purchased  by  the  czar,  Peter  the  Great,  but  a  part  of  it  was  lost 
before  it  reached  St.  Petersburg.  His  numerous  essays  relate  chiefly  to 
anatomy,  iiut  contain  some  surgical  observations. 

Joh.  Jac.  Rau  (l()(iS-1719),  a  native  of  Baden  and  an  a])])rentic.e  of 
a  barber  surgeon  in  Strasburg,  studied  at  Leyden  and  Paris  and  settled 
in  Amsterdam,  where  he  gave  lessons  in  anatomy  and  surgery,  to  the 
great  dissatisfactiou  of  Ruysch.  Having  learned  from  Frere  Jacques 
his  method,  he  improved  ujion  it  and  acquired  great  fame  as  a  lithoto- 
mist,  but  kept  secret  the  details  of  his  method,  which  was  p7-ol)ably  the 
lateral  o]teration.  He  wrote  nothing  of  importance,  but  had  many  dis- 
tinguisiied  pupils. 

To  this  period  belong  Abram  Titsingh  (1685-?)  of  Amsterdam,  city 
surgeon,  surgeon  of  the  admiralty,  and  master  of  the  Surgeons'  Guild,  who 
wrote  works  on  lithotomy,  spina  l)itida,  venereal  diseases,  etc.  which 
were  valuable  in  their  day;  Joh.  Daniel  Schlichting  (1703-?),  a  lecturer 
on  anatomy  and  surgery  in  Amsterdam  in  the  middle  of  the  century, 
said  to  have  been  the  first  to  perform  neurotomy  for  neuralgia  of  the 
fifth  pair;  Jos.  Monnikhof  (1707-87),  appointed  herniotomist  of  Am- 
sterdam in  1752,  who  in  1775  published  statistics  of  one  thousand  cases 
of  hernia,  the  first  collection  of  this  kind  which  had  appeared ;  and 
Charles  Faudacc]  (1691-175  ?)  of  Namur,  who  studied  in  Paris  under 
Petit,  and  published  Rtlftcxiom  sur  lex  ]j/ai/cx,  etc.  (Nanuir,  1735),  and 
Noarcau  traite  dcs  pinics  crarmcs-d-fci(  (Namur,  174(i). 

In  Ghent  the  leading  surgeon  was  Joh.  Palfyn  (l(i5O-1730),  educated 
in  Paris,  master  of  the  Barber-Surgeons'  Comj^any  in  Ghent  in  1698,  and 
professor  of  anatomy  and  surgery  in  1708.  He  is  best  known  by  his 
Anatomic  Chirun/ienlc,  first  published  at  Paris  in  1726,  and  the  first 
treatise  with  the  title  of  "  Surgical  Anatomy." 

In  the  last  half  of  the  century  the  most  celebrated  teacher  in  Hol- 
land was  Peter  Camper  (1722-89),  a  native  of  Ijeyden,  who  became  pro- 
fessor of  anatomy  and  surgery  in  Amsterdam  in  1755  and  professor  in 
Groningen  in  17(33.  He  was  one  of  the  most  learned  men  of  his  time, 
and  a  voluminous  writer  on  anatomy,  pathology,  and  medical  jurispru- 
dence. His  treatise  on  calculus  (1782),  his  dissertation  on  fracture  of  the 
patella  and  olecranon  (1789),  and  his  Irones  hcrniarum,  ])ublished  after 
his  death  by  Soemmering,  are  valuable  contributions  to  surgical  literature. 

Among  the    Italian    surgeons  of  the    eighteenth    century   the    best 


THE  HISTORY  AXD  LITERATURE  OF  SUROERV.  SI 

known  are  Benovoli,  tlu'  two  Xannonis,  Lancisi,  A^alsalva,  Tacconi, 
ami  Bertrandi. 

Antonio  Jiencvoli  (1(385-1756),  a  surgeon  of  Florence,  discovered  in 
1722  that  eataract  is  an  opacity  of  the  lens,  and  published  his  I>l-tcorsi 
(U  chirurr/id  in  1750.  He  discovered  the  principle  of  treating  stricture 
of  the  urethra  by  dilatation. 

Angelo  Xannoni  (1715-90)  studied  in  Florence  under  Bcnevoli,  and 
afterward  in  Paris  and  Rouen,  and  became  chief  surgeon  of  the  hos- 
pital Santa  Maria  Xuova  in  Florence,  attaining  great  rejiutation.  His 
principal  works  are  Trattafo  chirtdr/ico  sopru  la  ficiDpHcita  del  iiiedicnre 
i  malt  d'aftenenza  della  chirurgia  (1770)  imd  Jlemorie  sopra  aleani  ca-d 
rnri  di  chirurqia  (1776). 

Lorenzo  Nannoni  (1749-1812),  son  of  Angelo,  studied  under  his 
father,  and  became  surgeon  to  the  Hospital  of  the  Innocents  in  Flor- 
ence, where  he  g-ave  clinical  teaching.  His  ])rincipal  work  is  Trattafo 
delle  malcric  cliirinr/ichc,  tie.  (2d  ed.  •'}  vols.,  1793-94). 

Giovanni  ilaria  Lancisi  (1654-1720),  professor  of  anatomy  at  Rome 
and  physician  to  Popes  Innocent  XL  and  XII.,  is  best  known  as  an 
anatomist,  but  in  his  De  molu  cordis  et  aneurt/smatihiis,  first  published 
after  his  death  in  1728,  and  in  four  later  editions,  he  first  clearly  pointed 
out  the  difference  between  true  and  false  aneurism. 

Antonio  Maria  Valsalva  (1666-1723)  studied  at  Bologna,  graduating 
in  1687,  and  became  professor  of  anatomy  in  the  university  and  sur- 
geon to  the  Hospital  of  the  Incurables  in  1697.  His  chief  work  was 
De  awe  humana  tractatus  (1705). 

Gaetano  Tacconi  (1689-1782),  a  native  of  Bologna,  succeeded  Val- 
salva as  professor,  and  was  surgeon  to  the  hospital  Santa  Maria.  He 
wrote  Kofizia  dclla  fcrifa  e  della  ciira  chlrurglca  seguita,  etc.  (1738),  and 
De  rarls  qnihuftdatn  hcrniis,  etc.  (1751). 

Giovanni  Ambrogio  Bertrandi  (1723-65),  son  of  a  surgeon,  studied  at 
Turin  and  Paris,  and  in  1758  succeeded  Lotteri  as  professor  of  surgery 
at  Turin.  His  principal  work  is  his  Trattato  delle  operazioni  di  chi- 
rurgia  (2  vols.,  176."?),  which  ]iassed  through  several  editions  and  was 
translated  into  French  and  German.  His  collected  works,  Opere 
an(doiiiiche  e  ccrusiche,  w'ere  published  after  his  death  in  fourteen 
volumes  (1786-1802). 

At  the  beginning  of  the  eighteenth  century  there  were  few  edticated 
surgeons  in  London,  and  still  fewer  in  the  provincial  towns ;  there  was 
no  special  instruction  in  siirgerv  to  be  obtained  except  through  appren- 
ticeship ;  and  the  facilities  for  studying  anatomy  were  extremely  limited.' 
When  the  monasteries  were  broken  up  by  Henry  VIII.  the  hospitals, 
which  had  previously  liclongcd  to  the  Church,  became  the  proj)erty  of 
the  government.  St.  Bartholomew's  was  refounded  in  1544,  and  placed 
under  the  superintendence  of  Thomas  Vieary.  This  hospital  had  one 
physician  and  three  surgeons,  and  these  allowed  tlieir  pupils  and  appren- 
tices to  attend  and  witness  the  practice.  In  1()62  there  is  mention  of 
the  presence  of  such  students,  hut  no  formal  system  of  lectures  or  teacli- 
ing  seems  to  have  existed  until  after  1734,  when  leave  was  granted  for 

'  See  The  present  state  nf  chyrurgeri/,  by  T.  D.  (Loniion,  1703i,  in  wliicli,  amoiif;  otlier 
charlatans,  reference  is  made  to  "The  Unborn  Doctor  who  cut  off  a  vast  number  of 
women's  breasts  without  loss  of  blood.' 
Vol.  I.— 6 


82  THE  HISTORY  AND  LITERATURE  OF  SURGERY. 

any  of  tlic  surgeons  or  assistant  snrfjcons  to  road  lectures  in  anatomy  in 
the  dissecting-room  of  the  hospital,  and  in  17(j.3  a  course  of  lectures  on 
surgery  was  commenced  by  Percival  I'ott. 

At  St.  Thomas's  Hospital  tlie  first  mention  of  an  ap])rentiee  in  the 
books  is  in  1561.  The  Barber  Surgeons'  Company  was  diss;itisfied  with 
the  teaching  in  St.  Bartholomew's  and  St.  Thomas's  hospitals,  as  it  was 
losing  money  thereby,  and  in  1695  it  made  a  special  investigation  into 
the  complaints  as  to  the  manner  of  teaching  in  these  hosjMtals,  tlie  sur- 
geons to  which  declared  that  they  had  never  taken  an  ajjprentice  for  a 
less  term  than  seven  years,  but  that  some  of  the  apj)rentices  of  other  sur- 
geons were  allowed  at  times  to  witness  their  practice.  In  1702  the  gov- 
ernors of  St.  Thomas's  Hospital  took  the  matter  of  teaching  into  their 
own  hands,  and  passed  a  law  forbidding  ])U])ils  or  surgeons  to  dissect 
without  permission  of  the  treasurer.  In  1703  it  was  resolved  that 
no  surgeon  should  have  more  than  three  "  Cubbs ;"  in  1758  this  term 
was  altered  to  that  of  "  Dressers."  Lectures  on  anatomy  and  surgery 
began  with  C'heselden  about  1720,  and  the  Anatomical  School  may  be 
said  to  have  been  fairly  established  about  1780.' 

At  the  London  Hospital  the  entry  of  the  first  student  was  in  1742, 
two  years  after  the  commencement  of  the  hospital,  and  the  Medical 
School  was  fully  organized  upon  the  model  of  the  Edinburgh  Faculty 
in  1785. 

In  the  Orders  of  St.  Bartholomew,  dated  1633,  it  is  directed  "  that  no 
cliirurgeon,  or  his  man,  doe  trepan  the  head,  dismember,  or  j)erform  any 
great  oper'con,  but  with  the  approbation  or  by  the  direction  of  the  doc- 
tor." Special  operators  were  appointed  to  cut  for  the  stone  at  the  hos- 
pitals, a  Mr.  Mullins  doing  this  for  St.  Bartholomew's  and  St.  Thomas's. 

The  ^ledical  School  of  Guy's  Hospital  dates  from  1769,  in  which 
year  a  resolution  was  jiassed  by  the  governors  that  all  surgeons  of  the 
hospital  should  occasionally  give  lectures  to  tlie  pupils.  It  is  also  noted  : 
"  No  persons  are  to  be  entertained  as  pupils  but  such  as  have  served  five 
years  to  a  regular  Surgeon  or  Apothecary."  At  this  time  the  schools  of 
Guy's  and  of  St.  Thomas's  were  united,  the  surgical  lectures  being  given 
at  St.  Thomas's  and  the  medical  at  Guv's,  and  the  two  M-ere  known  as 
the  "United  Hospitals." ^ 

The  ill-assorted  union  of  sury-eons  and  barl)ers  formed  by  the  act  of 
1540  was  by  no  means  harmonious,  but  the  surgeons  were  unable  to  get 
rid  of  the  barbers  imtil  1745,  when  they  agreed  with  Mr.  Ranby,  Serjeant 
surgeon  to  the  king,  that  he  should  procure  the  act  of  Parliament  desired, 
and  that  in  return  lie  should  be  made  a  member  and  be  elected  as  master. 
The  act  of  1745,  incorporating  the  "Masters,  Governors,  and  G(aiinion- 
alty  of  the  Art  and  Science  of  Surgeons  of  London,"  pro^•ided  that  it 
should  be  governed  by  a  "  court  of  assistants,  composed  of  twenty-one 
members,  whose  office  was  for  life,  and  who  filled  their  own  vacancies 
by  election  from  the  freemen  of  the  comjiany."  Ten  of  this  court  of 
assistants  were  to  be  "  examiners,"  whose  office  was  also  for  life,  and  it 
was  a  penal  offence  for  any  one  to  practise  surgery  in  London  or  within 
seven  miles  of  the  same  without  having  been  duly  examined  and  licensed, 

'  See  Prospectus,  1877-78,  p.  11. 

''  See  A  Biographical  History  of  Guy's  Hospital,  hy  S.  Wilks  and  G.  T.  Bettany 
(London,  1892). 


THE  HISTORY  AXD  LITERATURE  OF  SURGERY.  83 

except  tliat  the  rights  of  members  of  the  College  of  Physicians  to  do  so 
were  not  to  be  interfered  with.  The  surgeons  on  their  separation  from 
the  barbers  took  nothing  witii  tliem  except  the  Arris  and  Gale  becpiests  ; 
tiie  iiall,  HItrary,  and  plate  remained  with  the  barbers,  and  the  new  com- 
pany had  to  i)rovide  a  building  lor  itself. 

The  condition  of  the  company  in  1790,  as  stated  by  ISIr.  Gunning, 
the  master  of  the  company,  in  his  address  at  the  close  of  his  term  of 
office,  was  as  follows  :  "  You  have  a  theatre  for  your  lectures,  a  room  for 
a  Library,  a  connnittee-room  for  your  Court,  a  large  room  for  the  recep- 
tion of  your  committees,  together  with  the  necessary  accommodation  for 

your  Clerk Your  theatre  is  \\ithout  lectures,  your  library  room 

without  books  is  converted  into  an  office  for  your  clerk,  and  your  com- 
mittee room  is  become  his  parlour,  and  is  not  always  used  even  in  your 
common  business,  and  when  it  is  thus  made  use  of  it  is  seldom  in  a  fit 
and  proper  state."  The  next  thing  tliat  appears  in  its  history  is  a  charter 
by  George  III.,  dated  1800,  for  consolidating  tlie  Royal  College  of  iSur- 
geons  of  London,  in  the  preamble  of  which  it  is  stated  that  "we  are 
informed  tiiat  the  said  Corporation  of  Masters,  Governors,  and  Com- 
monalty of  the  Art  and  Science  of  Surgery  of  London  hath  become 
and  is  now  dissolved."  This  charter  of  1800  simply  reiterates  the  act 
of  1745. 

Turning  now  to  Scotland,  we  find  tiiat,  in  1694,  Dr.  Archibald  Pit- 
cairn  returned  to  Edinburgh  from  Leyden  and  endeavored  to  establish  a 
medical  scliool,  which  lie  intended,  if  possible,  should  surpass  tiiat  of 
Leyden  ;  and  his  first  step  was  to  induce  a  surgeon  named  Monteith  to 
apply  to  the  town  council  for  a  grant  of  dead  bodies.  As  soon  as  the 
other  surgeons  heard  of  this,  tiiey  also  applied  for  tiie  .same  privilege. 
The  privilege  granted  to  the  surgeons  had  a  clause  to  the  eftect  "  that 
the  petitioners  shall  before  the  term  Michaelmas,  1697,  build,  repair,  and 
have  in  readiness  one  anatomical  theatre,  M'here  tiiev  shall  once  a  year 
(a  subject  ottering)  have  one  public  anatomical  dissection,  as  much  as 
can  be  shown  upon  one  body,  and  if  the  ftulzie,  this  presents  to  be  void 
and  null."  This  condition  was  complied  witli,  and  as  the  grant  required 
that  the  body  should  be  buried  within  ten  days,  tiie  surgeons  selected 
ten  of  their  number,  termed  "  operators,"  each  of  wiiom  lectured  one  day 
on  certain  specified  parts.  In  1705  this  .system  was  changed,  and  one 
surgeon  performed  the  duty,  wiiile  the  town  council  made  this  same  sur- 
geon professor  of  anatomy  in  the  university.  This  was  the  commence- 
ment of  the  Medical  School,  altliough  it  was  not  until  1726  that  it  was 
fully  formed  througli  the  influence  of  John  Monro,  an  army  surgeon 
who  had  settled  in  Edinl)urgli  in   1700. 

The  leading  surgeon  in  England  in  the  first  half  of  the  eighteenth 
century  was  William  Cheselden  (1688-1752),  a  pupil  of  William  Cowper, 
who  began  to  lecture  on  anatomy  in  1711  in  his  own  house,  and  continued 
his  teaching  afterwairl  at  St.  Thomas's  Hospital,  to  which  he  was 
ap[)ointed  assistant  surgeon  in  1718  and  surgeon  in  1719.  In  1723 
he  published  his  Treatise  on  the  high  operation  for  the  fitoiie.  Soon  after 
he  gave  up  this  and  perfected  liis  "lateral  operation  for  the  stone,"  an 
improvement  on  tiie  method  of  Frere  Jacques  and  Ran,  whicii  soon 
became  famous.  He  publisiied  a  paper  in  the  Philosophical  Transactions 
on  the  formation  of  artificial  pujiil,  wiiicli  operation  he  was  the  first  to 


84  THE  HISTORY  AND  LITERATUltK  OF  SURGERY. 

]icrf()rm.  In  1733  he  became  surgeon  to  St.  George's  Hospital  at  its 
loiiiidation,  retired  from  St.  Thomas's  in  1738,  and  was  one  of  the  hist 
wardt'Ms  of  tlie  15arher  8ui'geoiis'  ('ompany  immediately  before  the  sepa- 
ration of  the  surgeons  and  liaiiiei-s,  whieii  took  place  in  1744-45. 

His  pupil,  Sanuiel  Sharp  (1700-78),  was  elected  surgeon  to  Guy's 
Hospital  in  1733.  His  Treatise  on  the  ojxrations  of  surgery  (London, 
1739  ;  lOtli  ed.,  1782)  and  his  Critical  inquiry  into  the  present  state 
of  sinyery  (London,  1750  and  1761,  and  translated  into  French,  S])anish, 
and  German)  were  celeljrated  in  tiieir  day,  and  the  Critical  iia/niry  is 
still  a  most  interesting  book  to  the  surgeon.  He  devised  the  cylindrical 
form  of  the  crown  of  the  trephine  at  jiresent  used,  and  contributed  to 
the  knowledge  of  the  anatomy  of  hernia. 

William  Bromfield  (1712-92),  surgeon  to  St.  George's  Hospital  and 
surgeon  to  the  king,  published  his  L'hirurgical  observations  and  cases,  in 
two  volumes,  in  1773.  These  contain  a  number  of  valuable  improvements 
in  surgical  methods,  particularly  as  to  bilateral  lithotomy  and  the  com- 
pression of  the  subclavian  artery  above  the  clavicle  on  the  first  rib.  He 
also  clearly  points  out  the  proper  manner  of  ligating  the  artery  in  ampu- 
tations, using  the  tenaculum  to  draw  out  the  vessel,  so  that  the  nerve  and 
other  tissues  should  not  be  included,  but  he  used  a  flat  ligature.  That 
he  was  a  cool  operator  is  shown  in  a  case  of  lithotomy  which  he  reports 
in  the  second  volume  at  ])age  266,  in  which  the  intestines  protruded  into 
the  bladder,  and  in  which  he  first  extracted  three  stones  and  then  returned 
the  intestines,  with  result  of  a  perfect  cure. 

William  Beckett  (1684-1738),  a  London  surgeon,  wrote  Practical 
surgery  illustrated  and  improved :  being  chirurc/ical  observations  ....  made 
at  St.  Thomas's  Hospital  (London,  1740,  8vo),  also  A  collection  of  chirur- 
gical  tracts  (London,  1740,  8vo),  including  a  paper  on  new  discoveries 
relating  to  the  cure  of  cancers,  published  by  him  in  1711. 

Benjamin  Gooch,  a  surgeon  of  the  Norfolk  and  Norwich  Hospital  in 
1771,  published  a  volume  of  Cases  and  praciical  remarks  in  surgery 
(London,  1758),  and  a  collective  edition  of  his  works  appeared  in  three 
volumes  (London,  1792).  He  taught  that  in  case  of  a  wound  of  an 
artei'v  ligatures  must  lie  apjilied  both  aliovc  and  below  the  wt)und. 

John  Douglas  (?-1743)  was  a  Scotch  surgeon  who  gave  private  lec- 
tures on  surgery  and  anatomy  in  London  about  1720,  and  in  the 
same  year  published  an  account  of  the  performance  of  the  high  opera- 
tion for  the  stone  under  the  title  of  Lithotoniia  Donglas-fiana.  He  was 
conceited  and  quarrelsome,  and  jniblished  two  alnisive  pamphlets  on 
Cheselden,  by  whom  he  was  com])letely  overshadowed. 

His  l)rother,  James  Douglas  (1675-1742),  was  a  jihysician  who  settled 
in  London  about  1700,  and  was  a  distinguished  anatomist  and  obstetrician. 
He  puljlished  a  Description  of  the  peritoneum  (London,  1730,  4to),  in 
which  he  described  the  fold  of  the  peritoneum  which  is  still  known  by 
his  name. 

To  the  first  half  of  this  century  lielongs  one  of  the  greatest  itinerant 
quacks  known  to  history — viz.  .John  Taylor  (1708-67),  who  styled  him- 
self "  Chevalier,  ophthalmiater  pontifical,  imperial,  and  royal."  He  was 
born  in  Norwich,  and  in  1727  published  a  pamphlet  on  the  mechanism  of 
the  eye  and  on  cataract.  This  he  dedicated  to  Cheselden,  from  whom  he 
acknowledges  that  he  had  learned  all  that  he  knew  about  the  matter,  and, 


THE  HISTORY  AND  LITERATURE  OF  SURGERY.  85 

■while  tlie  work  was  boastful,  yet  it  was  not  more  so  than  some  otluT  jmlj- 
lieations  of  that  day.  Soon  after  this  period  lie  ai)pears  to  haye  giyen  up 
all  idea  of  respectable  practice,  and  tnvyelled  far  and  wide  oyer  Europe, 
advertisin<r  himself  extensiyely  in  eyery  place  that  he  came  to,  and 
publishing  for  the  same  purpose  a  large  number  of  pamijhlets  referring 
to  his  wonderful  cures.  His  autobiography,  published  in  three  yolunies 
(Loudon,  1762),  is  one  of  the  curiosities  of  literature. 

The  principal  English  surgeon  in  the  middle  of  the  century  was 
Perciyal  Pott  (1713-88),  who  became  assistant  surgeon  of  St.  Bartholo- 
mew's Hospital  in  1745  and  surgeon  in  1749.  His  eontril)utions  to 
.surgery  were  numerous  and  im])i>rtant,  especially  those  on  hernia, 
injuries  to  the  head,  hydrocele,  and  the  disease  of  the  spine  still  known 
l)y  his  name  as  "  Pott's  disease."  His  Treatise  on  ruptures  was  pub- 
lished in  175(3,  his  Practical  remarks  on  the  hi/drocelc,  in  1762,  and  his 
Beniark.s  on  that  kind  of  palst/  of  the  hirer  linihs  irliich  is  frequentljj  found 
to  accompany  a  curvature  of  the  spine,  in  1779.  His  Chirurgical  works 
appeared  in  1771,  and  there  were  four  later  editions,  besides  German, 
French,  and  Italian  translations. 

Alexander  Monro  (1697-1767),  a  pupil  of  Cheselden  and  of  Boer- 
haaye,  became  the  first  professor  of  anatomy  in  the  Uniyersity  of  Edin- 
burgh in  1725;  he  also  lectured  on  surgery  and  made  great  use  of  com- 
paratiye  anatomy.  He  founded  the  Royal  Infirmary  and  gaye  clinical 
lectures  on  surgery,  and  was  one  of  the  best  surgeons  of  his  time.  His 
writings  relate  chiefly  to  anatomy,  but  he  also  wrote  important  papers  on 
aneurism,  cataract,  hernia,  etc.  He  first  tried  to  cure  hydrocele  by  the 
injection  of  wine.  His  son,  Alexander  Monro  [secundus]  (1733-1817), 
succeeded  him  as  professor  of  surgery,  and  held  the  chair  until  1810, 
when  he  gaye  it  oyer  to  his  son  of  the  same  name,  Alexander  Monro 
[tertius]  (1773-1859),  who  resigned  in  1846,  the  professorship  haying 
thus  been  held  by  the  three  Monros  for  one  hundred  and  twenty-one 
years.  Although  the  chair  was  thus,  after  a  fashion,  hereditary,  the 
talent  did  not  descend  to  the  third  generation. 

The  next  name  to  be  mentir)ued  is  that  of  a  man  whose  works  mark 
an  epoch  in  the  deyelopment  of  surgery — -John  Hunter  (1728-93),  the 
yiituigest  son  of  a  Scotch  fjirmer.  His  brother  William,  ten  years  older 
than  himself,  haying  receiyed  an  excellent  education  according  to  the 
l)attern  of  that  time,  settled  in  London  and  began  to  lecture  on  anatomy 
•and  surgery  in  1746.  In  1748,  John  Hunter,  a  rough,  ignorant  youth, 
decidedly  addicted  to  low  company  and  amusements,  and  not  haying 
shown  the  slightest  taste  for  study,  joined  his  brotiier,  and  was  employed 
by  him  as  an  assistant  in  the  dissecting-room  which  he  had  just  estab- 
lished. He  soon  showed  that  he  had  found  his  proper  field  of  actiyity, 
and  after  one  year's  experience  was  able  to  take  charge  of  the  pupils 
and  to  direct  their  work.  William  Hunter  was  a  good  classical  scholar 
and  a  cultiyated  and 'polished  mm  of  the  world,  being  in  all  these 
respects  a  complete  contrast  to  his  brother,  who  decided  in  fayor  of 
-surgery  as  a  career,  and  studied  under  Cheselden  and  Perciyal  P<itt. 

The  brothers  entered  into  partncrshij)  in  1754,  John  deyoting  him- 
self mainly  to  anatomy  and  to  physiological  experimentation.  He  also 
began  to  deliyer  lectures,  but  he  was  by  no  means  attractiye  as  either 
a  writer  or  a  speaker,  and  in  the  latter  capacity  his  audience  neyer 


86  THE  IIISroRY  AND  LITKRATURE  OF  SURGERY. 

aniountcd  to  twenty  persons.  In  ]7()1  lie  joined  the  army,  jjoint;'  to 
tlie  Spanisli  l*eninsnhi,  and  remained  witli  it  until  17(j3,  durinfj;  w  iiieii 
time  he  colk'eted  the  observations  contained  in  his  treatise  on  ^runsliot 
wonnds.  On  his  return  lie  began  to  teaeh  anatomy  and  snrjiery  to 
private  pupils  or  apprentices,  in  which  undertakinjj  he  was  aided  by  his 
election  as  sure;eon  to  St.  Georij;e's  Hospital  in  17(j<S.  The  remainder  of 
his  life  was  sjient  in  this  work,  in  investigations,  and  in  the  formation 
of  the  splendid  museum  which  is  now  under  the  charge  of  the  lloyal 
College  of  iSurgeons  of  Ijondon. 

The  name  of  John  Hunter  is  familiar  to  all  surgeons  mainly  through 
his  recommendation  that  in  cases  of  aneurism  due  to  disease  t)f  the  artery 
the  artery  should  be  tied  in  the  sound  parts  between  the  aneurism  and 
the  heart ;  and  aside  from  this  and  his  great  museum,  very  few  persons, 
except  those  who  have  ])reparcd  Hnntcrian  orations  or  studied  them, 
could  probably  state  with  any  clearness  what  it  was  that  he  did  to 
acquire  the  reputation  which  he  possesses.  His  work  on  comj)arative 
anatomy  was  the  result  of  the  dissection  of  over  five  hundred  species 
of  animals,  in  the  course  of  which  he  made  innumerable  discoveries  and 
anticipated  many  comparatively  recent  observers ;  and  in  comparative 
physiology  it  was  even  greater,  being  so  far  in  advance  of  his  times  that 
it  was  not  comprehentled. 

The  treatise  on  Blood,  InJJaimnaiion,  and  Gunnhof  Woundti  is  usually 
considered  Hunter's  greatest  work  and  as  embodying  the  results  of  the  best 
part  of  his  researches.  This  work  was  completed  and  given  to  the  pi'ess 
during  the  last  year  of  Hunter's  life,  and  was  not  puldished  until  1794. 

The  merit  of  Hunter's  operation  for  aneurism  does  not,  as  Guthrie 
remarks,  lie  in  the  operative  process,  but  in  the  ))rinciples  upon  which 
it  is  founded.  The  dangers  arising  from  the  aj)j)licati()n  of  the  method  of 
Antyllns  to  aneurisms  produced  by  disease  of  the  artery  were  in  part  due 
to  the  danger  from  hemorrhage  w'hen  the  artery,  in  a  state  of  disease,  is 
ligated,  and  in  j)art  to  the  sup]niration  and  ulceration  which  follo\^'cd  the 
opening  of  the  sac.  But  Hunter,  reasoning  upon  e.\])eriments  made  by 
him  in  removing  portions  of  the  coat  of  arteries,  and  also  upon  the 
results  which  he  had  observed  with  regai'd  to  the  establishment  of  a 
collateral  circulation  in  cases  where  an  artery  had  been  obstructed,  said  : 
"  If  the  artery,  however,  cannot  be  tied  above  the  aneurism  in  the  ope- 
ration, whore  can  it  be  tied  if  the  limb  be  amputated?  \Miy  not  tie  it 
up  higher  in  the  sound  parts,  where  it  is  tied  in  amputation,  and  pre- 
serve the  limb  ?" 

He  first  performed  this  operation  in  1785,  placing  four  ligatures  on 
the  artery  with  various  degrees  of  tightness.  The  patient  was  cured  of 
the  aneurism,  but  died  of  other  complications  fifteen  months  afterward. 
In  the  second  operation  he  applied  only  one  ligature.  Hunter  prfibably 
was  not  aware  of  the  full  scope  and  value  of  his  suggestion.  He  con- 
sidered that  the  arteries  which  would  admit  of  the  operation  were  the 
carotids  above  the  sternum,  any  of  the  branches  of  the  external  carotids, 
the  subclavian  after  having  passed  the  scalcni  muscles,  and  the  crural 
after  having  passed  Poupart's  ligament  and  given  oif  the  large  muscular 
artery.  He  did  not  think  the  subclavian  should  be  tied  in  axillary 
aneurism,  because  he  would  doubt  as  to  the  soundness  of  the  artery, 
and  the  simie  with  the  femoral  where  it  passes  under  Poupart's  ligament. 


THE  HISTORY  AND  LITERATURE  OF  SURGERY.  87 

His  plan  was  opposed  by  Pott  and  Bromfield,  the  latter  of  whom  said  : 
"  An  extravagant  proposition  has  been  snggested  by  some  people  to  tie 
up  the  prineipal  trunk  of  an  artery  in  the  extremities.  I  once  saw  an 
attempt  of  this  kind  in  a  true  aneurism  of  tlie  ham,  in  which  I  shall 
only  remark  that  the  patient  died  ;  and  I  tlo  Itelieve  that  the  embarrass- 
ments which  occurred,  as  well  as  the  event  of  the  operation,  will  deter 
the  gentleman  who  performed  it  from  making  a  second  attempt  in  a  sim- 
ilar ease."  Hunter,  after  quoting  this,  says  :  "  Now,  unfortunately  either 
for  Mr.  Bronitield  or  myself,  this  is  the  very  case  from  which  I  have 
formed  favorable  ideas  of  the  success  of  future  operations  of  a  similar 
nature."  '  Pott,  writing  in  1777,  said  :  "  As  far  as  my  observation  and 
experience  go,  the  operation  for  aneurism  in  the  femoral  and  popliteal 
arteries,  however  judiciously  performed,  will  not  be  successful ;  that  is, 
will  not  save  the  patient's  iife.  I  have  tried  it  myself  more  than  once 
or  twice.     I  have  seen  it  tried  by  others  ;  but  the  event  has  always  been 

fatal Nor  have  I  ever  seen  any  other  operation  that  that  of 

amputation  which  has  preserved  the  life  of  the  patient." 

John  Hunter  was  a  tremendous  worker.  His  labors  Mere  almost 
incessant.  It  is  probable  that  his  ignorance  of  what  had  been  done  by 
others  was  not  so  great  as  most  persons  have  inferred  from  the  fiict  that 
he  rarelv  quotes  or  refers  to  others.  It  should  be  remembered  that  he 
W!is  for  a  long  time  associated  with  his  brother,  who  was  certainly  well 
ac(|uaiiited  with  medical  literature,  and  that  lie  daily  met  men  of  culture 
antl  information,  from  whom  he  must  have  learned  a  certain  amount  of 
what  was  going  on  elsewhere.  Some  of  his  greatest  work  was  eflected 
tlirough  his  pupils,  .Tenner,  Abernethy,  Astley  Cooper,  Physick,  Ever- 
ard  Home,  and  otliers,  all  of  whom  were  trained  by  him  and  perpet- 
uated and  expanded  his  teachings.  Since  his  day  mere  mechanical  dex- 
terity, with  some  knowledge  of  ointments  and  plasters,  is  no  longer 
thought  sufficient  for  the  stock  in  trade  of  a  surgeon.  The  peculiar 
combination  of  work  in  anatomy,  pathology,  and  surgery  pursued  by 
Hunter  has  been  accepted  to  a  large  extent  in  England  since  his  time  as 
a  model  of  training  fen-  a  surgeon,  and  most  of  the  modern  leading  sur- 
geons have  been  in  their  younger  days  teachers  of  anatomy  and  of  jiath- 
ology ;  which  fact  has  exercised  a  great  influence  upon  the  development 
and  methods  of  teaching  of  surgery  in  England. 

The  successor  of  Hunter  in  English  surgery  M-as  his  pupil  and  enthu- 
siastic admirer,  John  Abernethy  (17(34-18.31).  He  was  elected  assistant 
surgeon  to  St.  Bartholomew's  in  1787  on  the  retirement  of  Mr.  Pott,  and 
then  began  to  give  private  lectures  on  anatomy  at  his  own  house,  and  his 
success  was  such  that  the  governors  of  St.  Bartholomew's  were  induced 
to  build  a  lecture  theatre,  where  in  1791  he  began  to  lecture  on  anatomy, 
physiology,  and  surgery. 

Abernethy  was  the  first  to  ligate  the  external  iliac  artery  for  aneur- 
ism, in  1796,  and  in  1798  he  liga^ed  the  common  carotid  for  hemor- 
rhage. In  179.3  he  perfn-med  neurectomy  i'or  neuralgia  of  the  arm 
conunencing  in  the  finger,  and  proved  that  after  the  removal  of  half  an 
incli  of  the  nerve  reunion  occurred  and  the  skin  of  the  finger  resumed  its 
natural  sensibility.^    He  also  introduced  an  improvement  in  the  opening 

'  Works  of  John  Hiinler,  edited  by  J.  F.  Palmer  (London,  1837,  vol.  i.  p.  547). 
*  See  his  Surgical  Works  (new  edition,  vol.  ii.,  1S17,  p.  205). 


88  THE  HISTORY  AND  LITERATURE  OF  SURGERY. 

of  lumbar  abscesses  by  a  method  of"  ineision  wliicli  sljould  admit 'tlie 
least  possible  amount  of  air.  As  he  grew  older  he  ceased  to  o|)erate, 
and  devoted  himself  more  to  the  treatment  of  the  general  health  of  his 
patients.  The  Mork  by  \vhi<'h  he  is  best  known  is  his  ExKtn/  on  the 
constitutional  origin  of  local  di.seaneti.  Abernethy's  re])iitation  was  not 
due  to  his  books  so  much  as  it  was  to  his  lectures,  which  were  dramatic 
in  character,  and  given  with  certain  eccentricities  of  manner  and  speech 
which  considerably  contributed  to  his  rejiiitation. 

Henry  Cline  (1750-1X27)  was  a  j)upil  of  Hunter,  and  became  sur- 
geon of  St.  Thomas's  Hospital  and  president  of  the  Royal  College  of 
Surgeons  in  1823.  He  ^vas  lecturer  on  anatomy  and  surgery  in  the 
early  part  of  the  eighteenth  century  in  the  Aldersgate  School,  and  con- 
tributed largely  to  the  spread  of  the  new  ideas  of  Hunter.  He  wrote 
no  special  treatises,  but  had  a  number  of  distinguished  pupils. 

Sir  William  Blizard  (1743-1835),  a  pupil  of  Hunter,  became  sur- 
geon of  the  London  Hospital  in  1780  and  founder  of  its  medical 
school,  to  the  cost  of  which  he  contributed  largely.  He  was  twice 
president  of  the  College  of  Surgeons  and  founded  the  Jacksonian  prize. 
He  was  one  of  the  first  to  ligate  the  subclavian  and  the  first  to  ligate  the 
superior  thyroid  artery.     His  ])ul)lications  are  chiefly  in  journals. 

Sir  Everard  Home  (1 76.3-1  .S.32),  the  son  of  an  army  surgeon,  was  a 
pupil  of  John  Hunter,  \\ho  married  his  sister.  He  served  for  a  short 
time  in  the  army,  returned  to  London  and  became  Hunter's  assistant, 
was  appointed  assistant  surgeon  to  St.  George's  Hospital  in  1787,  and 
surgeon  to  the  same  in  1793,  after  Hunter's  death.  He  was  one  of 
Hunter's  executors  and  edited  his  works,  was  made  a  baronet  in  1813, 
and  resigned  his  position  at  St.  George's  in  1827.  He  ^vas  a  voluminous 
writer,  treating  on  strictures  of  the  ui'ethra,  on  lUcers,  on  diseases  of  the 
prostate,  on  comparative  anatomy,  etc.,  but  lost  his  reputation  as  an 
author  on  account  of  the  fact  that  he  destroyed  the  greater  part  of  the 
large  collection  of  Hunter's  manu.scripts,  of  which  he  had  obtained  tem- 
porary possession,  and  which  he  used  in  prejiaring  his  own  papers. 

Other  Loudon  surgeons  of  this  century  who  should  lie  mentioned  are 
Sir  Csesar  Hawkins,  surgeon  to  King  George  II.  and  King  George  III., 
and  surgeon  of  St.  George's  Hos])ital  from  1735  to  1774;  Thomas 
Gataker,  surgeon  of  St.  George's  Hosi)ital,  who  died  in  1769;  Joseph 
Waruer  (1717-1801),  a  pupil  of  Sharp,  who  became  surgeon  of  Guy's 
Hospital  in  1748,  first  ligated  the  common  carotid  in  1775,  and  wdaose 
Cases  in  Surgery  (London,  1754  ;  4th  cd.,  1784)  are  still  worth  reading; 
and  Sir  James  Earle  (1755-1817),  surgeon  of  St.  Bartholomew's  Hos- 
pital, Avho  is  best  known  by  his  Treatise  on  hydrocele  (London,  1791 )  and 
Observations  on  the  operation  for  the  stone  (London,  1793). 

Among  the  distinguished  provincial  surgeons  of  this  period  may  be 
mentioned  Alanson,  Park,  White,  Mynors,  and  Hey. 

Edward  Alanson  (1747-1823)  was  a  pupil  of  John  Hunter,  and  sur- 
geon of  the  Royal  Infirmary  at  Liverpool  from  1770  to  1794.  He 
published  Practical  obserratio)i>i  on  amputation  and  the  after-treedment 
(London,  1779),  in  which  he  recommended  a  method  for  obtaining  a 
more  complete  covering  for  the  end  of  the  bone  by  cutting  the  mus- 
cles from  below  upward. 

Henry  Park  (1744-1831)  was  a  student  of  Pott  and  Le  Cat,  and  was 


THE  HISTORY  AND  LITERATURE  OF  SURGERY.  89 

surgeon  of  the  Royal  Intinnary  at  Liverpool  from  17(17  to  1798.  His 
name  i^  connected  with  the  histurv  of  resection  of  the  knee  and  elbow. 

Charles  White  of  Manchester  pul)lished  his  Caneiiiii  SitrtjiTt/  in  1770, 
and  first  excised  the  head  of  tiie  luuncrus  in  1768. 

Robert  Mynors  (17oy-18U6),  a  surgeon  of  Bmningham,  published 
his  Practical  observations  on  amputation  in  1783,  and  his  History  of  the 
practice  of  trephining  the  skull,  etc.  in  1785. 

William  Hey  (1736-1819),  a  distinguished  surgeon  of  Leeds,  pub- 
lished in  181)3  his  Practical  Observations  in  Sure/eri/,  which  passed 
through  two  later  editions,  and  is  still  worthy  of  consultation.  He 
described  and  named  fungwi  hamatodes.  His  name  is  connected  with 
the  form  of  saw  devised  by  him  for  use  in  case  of  fracture  of  the  skull, 
and  with  a  mode  of  partial  amputation  of  the  foot. 

At  tlie  end  of  the  century  the  leading  surgeons  in  Edinburgh  were 
Benjamin  and  John  Bell. 

Benjamin  Bell  (1 749-1 8()())  was  a  \m\)\\  of  Monro,  and  l)ecame  a  sur- 
geon of  the  Royal  Infirmary  in  1772.  In  1778  he  publislied  A  treatise 
on  the  theory  and  management  of  idcers,  etc.,  which  went  through  nume- 
rous editions  and  translations.  His  System  of  surgery  (6  vols.,  Edin- 
burgh, 1783-87)  also  passed  through  many  editions,  and  was  trans- 
lated into  German  and  French,  being  the  favorite  systematic  treatise  for 
the  next  twenty  years.  He  insisted  strongly  on  the  im])ortance  of 
saving  skin  in  amputations  and  operations  for  the  removal  of  tumors, 
in  order  to  leave  as  little  as  possible  of  the  surface  of  the  wound  exposed. 

John  Bell  (1765-1820)  graduated  in  medicine  in  Edinburgh  in  1779, 
and  in  1790  opened  ii  private  school  for  anatomy,  surgery,  and  obstetrics. 
He  was  ambitious  and  energetic,  and  unsjiaving  in  his  criticisms  of  his 
seniors,  Monro  and  Benjamin  Bell,  thus  causing  o])])osition  to  his  school, 
which,  however,  was  popular  and  successful.  His  brother  Charles  was 
of  great  assistance  to  him  in  this  enterprise.  He  published  a  treatise  on 
anatomy  which  went  through  many  editions :  Discourse  on  the  nature 
and  cure  of  wounds  (Edinburgh,  1795,  with  several  editions  and  trans- 
lations) and  The  Principles  of  surgery  (3  vols.,  London,  1801-08,  4to), 
remarkable  for  the  beauty  of  its  engravings.  He  was  the  leading  ope- 
rating siu'geon  in  Edinburgh  for  nearly  twenty  years.  As  the  result  of 
a  bitter  controyersy  with  Gregory  the  number  of  surgeons  at  the  Royal 
Infirmary  was  in  1800  limited  to  six,  and  Bell,  with  others,  was  excluded, 
and  thus  lost  the  opportunity  for  clinical  teaching. 

The  story  of  the  rise  and  progress  of  surgery  in  Ireland  is  told  in  the 
History  of  the  Royal  College  of  Surgeons  in  Ireland  and  the  Irish  Schools 
of  Medicine,  by  Charles  A.  Cameron  (Dublin,  1886). 

In  1446,  King  Henry  VI.  established,  by  royal  charter,  a  fraternity 
or  guild  of  barbers  for  the  ])romotion  and  exercise  of  the  art  of  chirurgerv. 
In  1572,  Queen  Elizabeth  granted  a  second  charter  to  the  l)arbers  and 
surgeons,  ordering  that  they  should  be  called  the  "  Master  Wardens  and 
Fraternity  of  Barbers  and  Cliirurgeons  of  the  Guild  of  Saint  Mary  or 
Magdalene  in  our  city  of  Dublin,"  and  a  third  charter  was  grante(l  in 
1687  by  James  II.,  giving  them  full  power  of  the  guild  over  barbers 
within  six  miles  of  Dublin.  There  were,  iiowever,  a  certain  number  of 
surgeons  m4io  had  no  connection  of  any  kind  with  the  company,  being 
army  surgeons,  or  men  of  liberal  education  who  had  studied  in  the  uni- 


90  THE  HISTORY  AM)  LITERATVnE  OF  SURGERY. 

versities.  In  1745  the  company  hcfi;an  to  disintofrrate,  and  in  1784  the 
union  between  the  harbcr.s  and  tlie  surgeons  was  praetieally  dissolved  by 
the  creation  of  the  Royal  College  of  Surgeons  in  Ireland.  The  beginning 
of  teaching  in  I)ul)lin  is  due  to  Sir  Patrick  Dun  (1642-171."}),  president 
of  the  College  of  Physicians  in  Ireland,  who  left  a  becpiest  for  "one  or 
two  Professors  of  Physiek  to  read  ])ul>lick  Lectures  and  make  publick 
Anatomical  dissections  of  the  several  ])arts  of  the  human  Body  or  Body's 
of  other  animals,  to  read  Lectures  of  Osteolog}*,  Bandages,  and  operations 
of  Chirurgery,  to  read  Botanic  Lectures,  Demonstrate  Plants  puhlickly, 
and  to  read  Publick  Lectures  on  Materia  Medica,  for  the  Instruction 
of  Students  of  Physiek,  Surgery,  and  Pharmacy."  The  teaching  did 
not  actually  liegin  until  1744.  The  first  surgical  work  pulilished  in 
Ireland  apj)ears  to  be  A  Concise  and  Impartial  Account  of  the  Advan- 
tages avisiitg  to  the  Public  from  the  general  use  of  a  New  Method  of  Am- 
putcdion  (DuhWn,  1703,  pp.  13).  The  second  was  Ohserixdions  on  Wounds 
of  the  Head  (Dublin,  1776,  pp.  177).  This  was  published  anonymously, 
but  a])peared  in  a  second  edition  in  1778  under  the  name  of  the  author, 
AVilliam  Dease  (1752-98),  who  was  one  of  the  most  energetic  founders 
of  the  Royal  College  of  Surgeons,  and  one  of  the  first  to  lecture  in  it. 
He  was  a  very  successful  teacher,  and  in  addition  to  his  work  on  wounds 
of  the  head  he  published  An  Introduction  to  the  Theory  and  Practice  of 
Surgery  (London,  1780,  8vo)  and  a  work  on  midwifery  ^\hich  became  a 
popular  text-book. 

In  1765,  Sylvester  O'Halloran  (1728-1807),  a  surgeon  of  Limerick, 
Avho  had  studied  in  Paris,  London,  and  Leyden,  jiublished  at  London 
A  Complete  Treatise  on  Gangrene  and  Sphacelus  ;  vitlt.  a  new  Method  of 
Amputation,  which  was  a  valuable  contribution  to  the  literature  of  these 
subjects. 

The  Nineteenth  Centuky. 

The  salient  points  in  the  history  of  surgery  in  the  nineteenth  century 
are  the  discovery  of  anassthetics ;  the  establishment  of  aseptic  and  anti- 
septic surgery  upon  the  scientific  foundation  of  the  new  science  c)f  bacteri- 
ology ;  the  development  of  conservative  surgery  in  the  treatment  of  diseases 
and  injuries  of  the  extremities  and  of  plastic  and  orthopicdic  surgery  into 
a  specialt}' ;  the  rise  and  progress  of  abdominal  and  intracranial  surgery; 
the  entrance  of  two  new  nations,  the  United  States  and  Russia,  into  the  field 
of  surgical  discovery,  literature,  and  teaching ;  the  change  in  the  methods 
of  educating  surgeons ;  the  formation  of  surgical  societies  and  associations ; 
and  the  cosmopolitan  character  of  the  art  developed  by  rapid  international 
communication  and  liy  periodicals.  The  founding  of  nuiseums  like  those 
of  Hunter  and  Dupuytren,  the  removal  of  restrictions  on  the  study  of 
anatomy,  the  great  advances  made  in  pathological  anatomy  and  ex])eri- 
raental  pathology,  and  the  development  of  oi)hthalmology,  otology, 
gynsecology,  dermatology,  and  laryngology  into  their  present  highly 
specialized  forms,  have  also  exerted  a  strong  influence  upon  surgery  and 
the  work  of  the  general  surgeon. 

With  the  increasing  accunuilation  of  the  people  in  cities  have  come 
increased  demands  and  o|)portHnities  for  surgeons,  for  increase  of  hospi- 
tals and  medical  schools,  for  skilled  nursing,  ingenious  mechanics  for  the 
making  of  instruments  and  apparatus,  and,  in  short,  for  many  means  of 


THE  HISTORY  AND  LITERATURE  OF  SURGERY.  91 

carrj-ing  out  suggestions  for  improvcnieuts  through  tlic  aid  of  competent 
assistants. 

More  progress  in  the  art  has  been  made  since  liSUO  than  iiad  been 
made  in  the  two  thousand  years  preceding  that  date,  and  this  has  been 
largely  due  to  work  done  in  the  dissecting-room  and  in  the  laboratory. 
Consider  for  a  moment  some  of  the  differences  between  the  resources  of 
the  surgeon  of  ISOO  and  those  of  the  surgeon  of  tlu'  present  day.  The 
surgeon  of  1800  had  little  more  knowledge  than  had  ilippocrates  of  the 
chief  causes  of  danger  after  operations,  such  as  suppuration,  pya^nia,  or 
tetanus,  and  groped  wildly  for  means  to  avoid  them.  He  had  no  clinical 
thermometer,  and  could  only  guess  at  temperature  and  fever  ;  no  hypoder- 
mic syringe  ;  no  anaesthetic  ;  no  definite  knowledge  of  the  imjKirtanee  of 
blood-saving  or  of  the  best  means  of  doing  it.  He  knew  nothing  of  plastic 
surgery,  of  tenotomy,  of  the  ophthalmoscope,  or  of  the  use  of  the  niicro- 
.scope  in  diagnosis,  and  had  only  just  learned  how  to  ligate  arteries  and 
to  treat  ordinary  wounds  in  a  simple  and  sensible  way.  The  really  great 
surgeon  of  that  day  who  was  bold,  cool,  and  skilful  could  perform  most 
of  the  great  oi)erations,  such  as  amputation,  ligature  of  hirgo  arteries, 
removal  of  tumors,  Csesarean  section,  and  the  like,  but  such  men  were 
few  and  far  between. 

At  the  beginning  of  the  century  London  was  the  centre  of  surgical 
improvement  and  of  surgical  teaching,  and  the  leading  siu'geons  at  that 
time  were  Abernethy,  Cline,  Blizard,  Home,  Astley  Cooper,  Lawrence, 
and  Wardrop.  The  first  four  of  these  have  been  referred  to  in  a  pre- 
vious section. 

Astley  Paston  Cooper  (17(38-1841),  a  native  of  Norfolk,  was  appren- 
ticed in  1784  to  his  uncle,  William  Cooper,  surgeon  to  Guy's  Hospital, 
and  was  soon  transferred  to  Cline,  then  surgeon  at  St.  Thomas's.  He 
attended  John  Hunter's  lectures  and  spent  one  winter  at  the  Edinburgh 
Medical  School,  was  appointed  demonstrator  of  anatomy  at  St.  Thomas's 
in  17851,  and  two  years  later  became  joint  lecturer  with  Cline  in  anatomy 
and  surgery.  In  1800  he  was  appointed  surgeon  to  Guy's  on  the  resig- 
nation of  his  uncle.  In  1805  he  ligated  the  common  carotid  for  aneurism, 
and  in  1817  the  abdominal  aorta.  In  1820  he  performed  a  simple  opera- 
tion on  King  George  IV.,  which  resulted  in  his  being  made  a  liaronet. 
In  182.5  he  resigned  his  lectureship  at  St.  Thomas's  and  induced  the  for- 
mation of  a  separate  medical  seliool  at  Guy's,  in  which  his  pupil,  Aston 
Key,  lectured  on  surgery,  and  his  ne]iiiew,  Bransby  Cooper,  on  anatomy. 
He  was  an  extremely  skilled  anatomist,  and  some  of  his  most  valuable 
contributions  are  connected  with  his  work  in  this  direction.  Among  them 
may  be  mentioned  his  treatises  on  hernia  (in  two  parts,  1804—07),  the 
second  edition  of  which  ap])eared  in  1827,  the  illustrations  to  which  are 
said  to  have  been  so  expensive  that  he  lost  a  thousand  pounds  by  the 
publication.  His  book  on  Dislocations  and  Fractures  of  the  Joints 
was  published  in  182"J;  his  Lccfures  on  the  Principles  and  Practice 
of  8urf/eri/,  with  additions  by  Tyrrell,  in  three  volumes,  in  1824—27  : 
the  eighth  edition  of  this  appeared  in  18;17  ;  and  his  Illustrations  of  Dis- 
eases of  the  Breast,  Part  I.,  in  1829;  his  observations  on  the  Structure 
and  Diseaiies  of  the  Testes  in  1830;  and  his  work  on  the  Anatomy  of 
the  Breast  in  1840.  He  seems  to  have  read  little,  his  books  contain  few 
references  to  the  work  of  other  men,  and  his  reputation  and  iuHuence 


92  THE  HISTORY  AND  LITERATURE  OF  SURGERY. 

were  due  more  to  his  personality  and  his  great  skill  as  an  operator  tiiaii 
to  his  ('ontril)iiti()ns  to  science  or  practice. 

William  Lawrence  (17S.')-1.S()7),  tlie  son  of'a  surfruoii,  was  a  pupil  of 
Abernethy  and  liis  demonstrator  of  anatomy  for  twelve  years.  He 
became  a  member  of  tiie  Collejic  of  Surgeons  in  1805,  won  its  prize  for 
an  essay  on  hernia  in  18()(),  was  ai)pointed  assistant  surgeon  to  St.  Bar- 
tholomew's Hospital  in  181.3,  and  in  1815  became  professor  of  anatomy 
and  physiology  at  the  College  of  Surgeons.  His  lectures  were  considered 
to  flavor  of  infidelity,  and  led  to  a  sharp  controversy,  which  ended  by  his 
recanting  the  objectional)le  opinions  and  withdrawing  his  l)ook,  On  the 
Hixtory  of  Man,  from  sale  as  far  as  he  could.  He  was  connected  with 
the  Aldersgate  ]\Iedieal  School,  and  in  1823  succeeded  Aliernethy  as 
lecturer  on  surgery  at  St.  Bartholomew's.  His  principal  contributions 
to  surgical  literature  are  his  Trcafii^e  on  Diseases  of  the  Et/e  (1833)  and 
his  Lectures  on  Suiyeri/,  jtublished  in  18<!3.  He  was  a  skilled  anatomist, 
an  elo(]uent  lecturer,  and  an  erudite  author. 

James  Wardrop  (1782-1869),  a  native  of  Scotland  and  educated  in 
Edinl)urgh,  came  to  London  in  180'(.  In  1826  he  founded  a  hospital 
under  the  title  of  the  "  \A'^est  London  Hospital  of  Surgery,"  and  in  the 
same  year,  in  conjimction  with  Mr.  Ijawrence,  gave  a  course  of  lectures 
at  the  Aldersgate  Street  School.  His  abusive  articles  in  The  Lancet  in 
1826-27  probably  prevented  him  from  having  any  official  connection 
with  the  colleges.  In  1828  he  was  made  surgeon  to  the  king.  He 
wrote  for  The  Lancet  (1834,  vol.  ii.)  a  series  of  grossly  personal  and 
abusive  papers  entitled  "  Intercepted  Letters,"  purporting  to  be  written 
by  Halford,  Brodie,  MclNIichacl,  and  others,  after  which  the  heads  of 
the  profession  in  London  had  as  little  as  possible  to  do  with  their 
author.  In  1835  he  joined  the  Hunterian  School  of  Medicine  and 
gave  a  course  of  lectures  on  surgery.  His  best-known  work  is  that  on 
the  diorbid  Anatomi/  of  the  Eye.  His  name  in  the  history  of  surgery  is 
chiefly  connected  with  the  operation  first  proposed  by  Brasdor  for  the 
cure  of  aneurism  by  placing  a  ligatui-e  on  the  distal  side  of  the  tumor, 
which  operation  Mr.  Wardrop  jierformed  successfully  in  two  cases  of 
aneurism  of  the  carotid  artery,  and  in  one  ease  of  aneurism  of  the  innom- 
inate artery,  in  M'hich  he  tied  the  subclavian. 

The  following  surgeons  also  belong  to  the  early  part  of  the  century  : 

Joseph  C.  Carpue  (1764-1846),  who  in  An  Account  of  two  Successful 
Operations  for  Eestoring  a  L^ost  Nose,  etc.  (London,  1816,  4to),  intro- 
duced rhinoplasty  by  the  Indian  method,  and  recalled  attention  to  the 
high  operation  for  stone  in  his  excellent  historical  sketch.  The  History 
of  the  Hir/li    Operation  for  the  Stone  (London,  1819). 

Samuel  Cooper  (1 780-1848),  surgeon  of  the  I^niversity  College  Hos- 
l)ital  from  1831  to  1848,  published  his  Surc/ical  Dictionary  in  1809,  the 
first  comprehensive  and  complete  work  of  the  kind  in  existence,  and  the 
continued  pojndarity  of  which  is  shown  by  the  fact  that  its  eighth  edition 
was  })ublished  in  1861-72.  Every  edition  is  valuable  to  the  student  of 
the  progress  of  surgery  in  the  nineteenth  century. 

Alexander  Copland  Hutchinson,  a  naval  surgeon,  published  Practical 
Observations  on  Surgery  in  1816  (2d  ed.  1826),  and  Some  further  Obser- 
vations on  the  subject  of  the  proper  period  for  Amputating  in  Gunshot 
Wounds,  etc.,  in  1817. 


THE  HISTORY  AXD  LITERATURE  OF  SURGERY.  93 

Charles  Aston  Key  (1793-1849),  a  pupil  of  Astley  Cooper,  whose 
niece  he  married,  beeanie  demonstrator  of  anatomy  at  St.  Thomas's 
Hospital  in  18'2(),  assistant  surgeon  to  Guy's  Hosj)ital  in  1821,  surgeon 
to  the  same  in  1824,  and  professor  of  surgery  in  its  sehool  in  1825.  He 
ligated  the  subelayian  artery  in  1825,  and  tied  the  carotid  for  aneurism 
in  1830 ;  introduced  the  use  of  the  straight  staff  in  lithotomy,  and  the 
method  of  diyiding  the  stricture  external  to  the  sac  in  strangulated 
hernia,  and  was  one  of  the  most  popular  teachers  in  London. 

From  1820  to  1835  the  leading  London  surgeons,  in  addition  to  those 
already  referred  to,  were  Brodie,  Bell,  and  Trayers. 

Sir  Benjamin  Collins  Brodie  (1783-1862)  was  a  native  of  Wiltshire, 
England.  He  studied  in  London,  and  began  to  assist  in  teaching  at  the 
AVindmill  Street  School  in  1805,  when  he  was  twenty-two  years  of  age. 
In  1803  he  became  the  pupil  of  Sir  Eyerard  Home,  and  in  1808  assistant 
surgeon  at  St.  Thomas's  Hospital,  where,  in  1822,  on  the  death  of  Mr. 
Griffiths,  he  liecame  full  surgeon,  from  which  position  he  retired  in  1840. 
He  deyoted  himself  largely  to  physiological  experiments,  some  results  of 
which  appeared  in  the  celebrated  Croonian  Lecture,  delivered  in  1810,  on 
the  influence  of  the  brain  on  the  action  of  the  heart,  in  which  he  re})orted 
the  results  of  the  use  of  the  woorara  poison,  and  in  a  pa])er  published  in 
1814  on  The  Influence  of  the  Pneumof/adric  on  the  iSecretions  of  the  tStom- 
ach.  Of  his  surgical  writings,  the  first,  and  perhaps  the  most  important,  is 
his  Pafholofjieal  and  Surgical  Observations  on  the  Diseases  of  the  Joints, 
published  in  1818,  and  appearing  in  a  fifth  edition  in  1851.  His  lectures 
On  Diseases  of  the  Urinary  Organs  appeared  in  1832,  a  fourth  edition 
being  issued  in  1849.  In  1846  he  published  a  volume  of  lectures  on 
various  subjects  in  pathology  and  surgery.  His  complete  works,  \\ith 
an  autobiography,  are  ])ublished  in  three  volumes  (8yo,  London,  1865). 
He  devoted  himself  to  the  scientific  side  of  surgery  rather  than  to  opera- 
tions, although  he  was  a  very  successful  operator,  and  for  over  thirty 
years  was  recognized  as  the  head  of  the  medical  profession  in  London. 
Sir  Charles  Bell  (1778-1842)  was  a  younger  l;>rotiier  of  John  Bell  of 
Edinburgh,  under  whom  he  studied  and  whom  he  soon  began  to  assist  in 
the  teaching  of  anatomy.  In  1804  he  went  to  London,  where  he  began 
to  teach  in  his  own  house  in  1807,  after  which  he  associated  himself  with 
Mr.  Wilson  in  the  Great  Windmill  Street  School,  where  he  came  into  com- 
petition as  a  teacher  with  Cline,  Cooper,  and  Abcrncthy,  and  met  with 
great  success.  In  1812  he  began  to  deliver  clinical  lectures  in  the  INIid- 
dlesex  Hospital,  to  whi<'h  he  was  appointed  surgeon  in  1814.  In  1836 
he  accepted  the  chair  of  surgery  in  the  University  of  E(linl)urgh,  wliich 
he  held  until  his  death.  His  publications  were  voluminous,  and  include 
his  System  of  Operative  Surgery  (2  vols.,  1807-09),  his  paper  on  Gunshot 
Wounds  (in  1814),  his  Surgical  Observations  (2  vols.,  London,  1816-18), 
and  his  Illustrations  of  the  Great  Operations  in  Surgery,  etc.  {in  1821). 
His  fame,  however,  is  'mainly  due  to  his  ])a]K'rs  relating  to  the  ner- 
vous system,  the  result  of  careful  and  long-continued  experimental 
work.  His  Idea  of  a  JVew  Anatomy  of  the  Brain,  printed  in  1811,  is  a 
pamphlet  of  36  pages  Avhich  forms  an  epoch  in  the  history  of  discoveries 
relating  to  the  structure  and  functions  of  that  organ.  He  was  a  skilled 
artist,  a  dexterous  operator,  and  a  conscientious  and  popular  teacher, 
whose  fame  has  increased  instead  of  diminishing;  since  his  death. 


94  THE  HISTORY  AND  LITKHATUIiE  OF  SURGERY. 

Bcnjaiuin  Travel's  (ITSS-LSoS)  was  a  pupil  of  Astlcy  Cooper,  pro- 
sector of"  anatomy  at  (Jiiy's  Hos])ital,  and  surgeon  of  St.  Tliomas's  Hos- 
pital in  1815.  He  was  a  skille(l  oplitlialniolof^ist,  and  liis  tS}/iioj)xin  of  the 
Diseases  of  tlie  ]'Ji/c  (1X20)  was  tlie  hest  systematic  treatise  on  that  subject 
which  had  yet  appeared  in  Eni;lish.  His  tastes  led  him  to  the  scientific 
rather  than  to  the  practical  aspect  of  surgery,  and  his  treatises  on  C'on-\ 
dituflonal  Irritation  (1824),  A  further  Inquiry  concerninr/  Constitutional 
Irritation  and  the  J\ifhologi/  of  the  Nervous  Si/stetn  (18.34),  and  The 
Phi/sioloffi/  of  Inflainination  (1844)  are  specimens  of  physiologico-])atli- 
ological  investigation  of  the  highest  order  of  merit.  He  contributed 
some  valuable  papers  on  aneurism  and  the  ligature  of  arteries  to  the 
Medieo-chirurgieal.  Transactioyis,  and  one  on  wounds  of  the  veins  in  the 
8urf/ieal  Essai/s,  ])ul)lished  by  Astley  Cooper  and  himself  in  1818-19. 
He  introduced  tiie  use  of  mercury  in  non-specific  iritis  and  in  other 
forms  of  inflammation.  Of  all  the  English  surgeons  of  this  period, 
there  are  none  wiiose  writings  are  more  interesting  to-day  than  are  those 
of  Travers. 

In  Edinburgli  there  was  no  surgeon  of  special  note  engaged  in  teach- 
ing after  John  Bell  was  excluded  from  the  infirmary  and  gave  up  his 
school.  No  separate  chair  of  surgery  was  established  in  the  university 
until  1831,  owing  to  the  persistent  opposition  of  the  second  Monro,  who 
claimed  to  be  professor  of  surgery  as  well  as  of  anatomy.  A  chair  of 
surgery  was  instituted  in  the  College  of  Surgeons  in  1804,  which  was 
maintained  until  the  chair  was  created  in  the  university  in  1831,  and 
this  was  filled  by  Dr.  John  Thomson  (1765-1846),  who  became  surgeon 
of  the  Royal  Infirmary  in  ISDO,  and  began  to  give  clinical  lectures 
therein  on  surgery  in  the  private  theatre  in  1801,  this  being  then  the  only 
sejiarate  course  on  this  subject  given  in  the  city.  In  1806  a  chair  of 
military  surgery  was  instituted  in  the  university,  to  which  Dr.  Thomson 
was  appointed.  His  Lectures  on  Infiammation,  etc.  (Edinburgh,  1813) 
passed  through  several  editions  and  translations,  and  his  Report  of  Ob- 
servations made  in  the  British  Military  Hospitals  in  Belgium  after  the 
Battle  of  Waterloo,  etc.  is  of  interest  to  army  surgeons. 

A  chair  of  clinical  surgery  was  created  in  the  university  in  1803, 
Avhich  was  filled  by  the  appointment  of  James  Russell,  a  surgeon  of  the 
Royal  Infirmary,  who  published  in  1794  A  Practical  Essay  on  a  certain 
Disease  of  the  Bones  termed  Necrosis  (Edinburgh,  8vo),  and  in  1833, 
after  his  retirement,  Observedions  on  the  Ti'sticlcs. 

Sir  George  Ballingall  (1780-1855)  entered  the  army  in  1806,  and 
became  professor  of  military  surgery  in  the  university  in  1823.  His 
principal  work  is  his  Outlines  of  the  course  of  lectures  on  Military  Sur- 
gery, etc.,  published  in  1833,  which  reached  a  fifth  edition  in  1855. 

Here  also  may  be  mentioned  John  Hennen  (1779-1828),  a  distin- 
guished English  military  surgeou,  a  native  of  Ireland,  who  studied  in 
Dublin  and  Edinburgh,  and  entered  the  army  in  1800.  His  chief  work 
is  Observations  on  .sy>//;<'  important  poiids  in  the  practice  of  3Iilifary  Sur- 
gery, etc.  (Edinburgh,  1818),  and  subsequent  editions,  called  Principles 
of  Military  Surgery  (Edinburgh,  1820). 

In  Glasgow  at  the  beginning  of  the  century  the  leading  surgeon  was 
John  Burns  (1775-1850),  M'ho  was  the  first  lecturer  on  anatomy  who  was 
unconnected  with  tlie  university.     His  Principles  of  Surgery  (2  vols., 


THE  HISTORY  ASD  LITERATURE  OF  SURGERY.  95 

Loiiilon,  1829-38)  was  dry  ami  lunl  no  success,  but  his  Principles  on 
3Ii(ltrif('ri/  reached  a  tenth  edition.  In  I8I0  he  was  appointed  Regius 
professor  of  surgery  in  the  University  of  Ghisgo\\-,  and  held  this  position 
until  his  death. 

Allan  liurns  (1781-181o)  was  a  brother  of  John,  whose  demonstrator 
he  became  in  the  anatomical  school.  He  first  described  the  falciform 
process  of  the  fascia  lata  in  its  relations  to  femoral  hernia  in  a  pa])er 
wliich  he  puljlished  in  the  Edinliuiyh  Mviliail  Journal  in  180(5.  His 
Observationn  on  the  Surr/ieal  Anatomi/  of  the  J  [cad  and  Neck  (Glasgow, 
1811)  is  a  valuable  surgical  work,  which  contains,  in  addition  to  the 
anatomy,  accounts  of  numerous  cases  of  tumors  in  this  region,  a  discus- 
sion on  the  treatment  of  aneurism,  etc.  He  suggested  the  ligature  of 
the  innominate  artery,  and  it  was  this  suggestion  which  led  to  the  first 
performance  of  the  operation  by  INIott  in  1821. 

Between  1825  and  1840  four  surgeons  in  Edinburgh  became  distin- 
guished, and  two  of  them  were  transferred  to  London  to  take  high  places 
there.     These  four  were  Lizars,  Liston,  Fergusson,  and  Svme. 

John  Lizars  (1783—1860)  was  a  pupil  of  John  Bell,  and  began  to 
teach  anatomy  in  a  private  school  in  1815.  In  1831  he  became  pro- 
fessor of  surgery  in  the  Royal  College  of  Surgeons.  He  was  the  first 
in  Scotland  to  ligate  the  innominate,  and  the  second  to  perform  ovariot- 
omy, an  operation  which  became  known  maiidy  through  his  Obsermtions 
on  Extirpation  of  Disea><ed  Ovaria  (Edinburgh,  1825,  fob).  His  name 
is  also  connected  with  early  operations  for  excision  of  the  jaws.  In 
1839  he  ceased  teaching  and  devoted  himself  to  private  practice.  He 
was  a  skilled  anatomist  and  a  brilliant  and  daring  operator. 

Robert  Liston  (1794-1847),  a  native  of  Scotland,  was  educated  in 
Edinl)urgh  and  Lctndon,  and  l)egan  to  teach  anatomy  in  1818.  In  1823 
he  gave  uj>  this  teaching  in  favor  of  Syme  and  devoted  himself  entirely 
to  surgery.  He  became  surgeon  of  the  North  London  Hospital  and 
professor  of  clinical  surgery  in  University  College,  Loudon,  in  1834, 
and  rapidly  achieved  a  great  success.  He  was  possessed  of  great  per- 
sonal strength  and  was  a  brilliant  operator,  having  the  reputation  of 
being  the  most  dexterous  surgeon  of  his  time.  His  method  of  fiap- 
amputatiou  became  very  popular,  and  he  made  numerous  contributions 
to  the  surgery  of  ani])utation,  aneurism,  lithotomy,  and  lithotrity.  He 
would  amputate  the  thigh  with  only  the  aid  of  one  person  to  hold  the 
limb  and  tie  the  ligatures,  compressing  the  artery  with  his  left  hand, 
using  no  tourniquet,  and  doing  all  the  cutting  and  sawing  witli  the 
right.  A  large  part  of  his  skill  and  success  was  due  to  his  knowledge 
of  anatomy,  wliich  he  kept  up  by  dissections  throughout  his  life.  He 
excised  the  upper  jaw  for  a  formidable  tumor  in  1836,  and  the  success  in 
this  instance  brought  to  him  a  crowd  of  cases.  His  rashness  is  exempli- 
fied in  the  celebrated  case  in  which  he  punctured  an  aneurism  of  the 
carotid,  su])])()sing  it  to'be  an  abscess,  although  his  house-surgeon  had 
told  iiim  that  the  tumor  ])uls;ited.  His  principal  ])ublications  were  his 
Elcnient.s  of  ,S»;Y/f/v/,  published  in  l.S;51,and  his  Practie(d  Surgery,  in 
1837,  both  of  which  works  went  through  several  editions. 

William  Fergusson  (1808-77),  a  native  of  Scotland,  was  educated  at 
Edinburgh,  being  a  ])upil  of  Robert  Knox.  In  1831  he  was  elected 
surgeon  to  the  Edinburgh  Royal  I)ispens;iry,  being  at  this  time  lectur- 


96  THE  msTonr  am)  liticrature  of  simnEnr. 

ing  on  surgical  anatomy  in  association  with  Knox,  and  was  tiic  first  to 
ligate  the  subclavian  in  Scotland.  In  1840  he  accepted  the  professor- 
ship of  surgery  at  King's  College,  London.  In  ISo;")  he  was  a|)pointed 
surgeon  extraordinary,  and  in  LSIw  serjeant  surgeon  to  tiie  queen.  For 
many  years  he  was  tiie  leading  surgical  operator  in  London.  He  resigned 
his  professorship  of  surgery  in  1870,  but  remained  clinical  ])rofessor  of 
surgery  and  senior  surgeon  at  King's  College  Hospital  until  his  death. 
He  was  created  a  baronet  in  1866.  His  special  contributions  to  the  art 
were  largely  in  the  line  of  what  he  called  "conservative  surgery,"  a 
term  which  he  first  apjilied  in  1852  to  the  avoidance  of  anqintation  l)y 
means  of  resections  and  to  the  removal  of  no  more  than  is  alisolutely 
necessary  in  cases  of  diseases  of  the  bones.  His  name  is  especially  asso- 
ciated with  operations  of  hare-lip  and  cleft  palate,  \\'itli  operations  on  the 
jaws,  the  excisicm  of  joints,  and  with  lithotomy  and  lithotrity.  His 
principal  contribution  to  literature  is  his  System  of  Practical  Siirf/crt/ 
(London,  1842;  5th  ed.  1870).  He  also  contrilnited  many  valuable 
papers  to  the  periodicals.  His  lectures  on  the  Pror/rcss  of  Aiuitomj/  and 
Surgery  during  the  Present  Century  (1867)  are  extremely  interesting  to 
the  student  of  the  history  of  surgery. 

James  Syme  (1799-1870)  was  a  jiupil  of  Dr.  Barclay,  and  when  only 
nineteen  years  old  was  entrusted  with  the  charge  of  his  cousin  Listen's 
anatomical  rooms,  in  which  he  began  to  teach  in  1S22.  In  1825  he 
began  to  teach  surgery,  but,  having  quarelled  with  Liston,  he  had  no 
chance  to  obtain  an  appointment  in  the  Royal  Infirmary,  and  therefore 
started  a  private  hospital.  When  he  succeeded  Kussell  in  the  clinical 
chair  in  the  university,  he  became  one  of  the  surgeons  of  the  infirmary 
in  1833,  and  after  Liston  went  to  London  in  1834  the  greater  part  of 
the  operative  surgery  of  Scotland  fell  into  his  hands.  In  1831  he  pub- 
lished his  treatise  on  the  Excision  of  Diseased  Joints,  which  was  the  fir.st 
systematic  attempt  to  show  that  excision  ought,  in  most  cases,  to  super- 
sede amputation,  and  it  had  the  greatest  influence  in  bringing  about  this 
change  in  practice.  The  first  edition  of  his  Principles  of  Surgery  was 
published  in  1822  ;  the  fifth  edition  in  1863.  This  is  an  extremely  con- 
cise work,  and  the  fifth  and  last  edition  is  smaller  than  the  first.  In 
1847  he  pul)lished  his  Contributions  to  the  Pathology  and  Practice  of  Sur- 
gery, in  which  he  gives  an  account  of  the  first  eight  cases  of  amputation 
at  the  ankle-joint  by  the  method  which  is  still  known  by  his  name.  The 
date  of  his  first  case  of  this  kind  is  September  8,  1842.  In  1847  he 
accepted  a  call  as  surgeon  to  LTniversity  College,  London,  on  the  tleath  of 
Liston,  but  he  did  not  find  the  place  satisfactory,  and  four  months  later 
he  returned  to  Edinburgh.  He  was  a  bold,  cool,  and  skilful  operator, 
but  not  a  rash  one.  Among  his  most  remarkable  operations  may  be 
mentioned  those  for  aneurism  by  incision  of  the  tumor  and  ligations 
above  and  below,  M'hich  operation  he  performed  in  cases  of  aneurism  of 
the  carotid,  the  axillary  artery,  and  the  iliac  artery. 

In  1835  the  greater  part  of  the  medical  teaching  in  London  was  still 
given  in  private  schools  having  no  connection  with  hospitals,  the  oldest 
and  best  known  In'ing  the  Windmill  Street  and  Aldersgate  Street  Schools. 
The  Great  Windmill  Street  School  was  established  by  William  Hunter 
about  1746,  and  numbered  among  its  teachers  the  two  Hunters,  Baillie, 
Cruikshank,  ^\'ilson,   ]Mayo,  Shaw,   Brodic,  Charles  Bell,   Carpue,  and 


THE  HISTORY  AM)  LITERATURE  OF  SUROERY.  97 

Cffisar  Hawkins,  hut  was  linally  destroyed  by  the  estahlishment  of  tlie 
I^oiidon  University  in  the  vicinity  of  the  Middlesex  Hospital  in  LS3G. 
The  Aldersgate  School  was  also  of  old  date,  and  nnnihered  ainono-  its 
teachers  ^^'ardrop  and  Lawrence. 

The  hospital  schools  of  Guy's  and  St.  Thomas's,  which  had  been 
nnited  in  17<J8,  the  surgical  lectures  being  given  at  St.  Thomas's  and 
the  medical  at  Guv's,  were  ]iracticallv  separated  in  182o,  and  entirely 
so  in  183(3. 

After  Liston  and  Fergusson  came  to  Ijondon  clinical  hospital  teach- 
ing increased  rapidly  in  favor  and  importance;  the  hospital  schools 
began  to  flourish  and  the  private  schools  to  disappear.  At  this  period, 
in  addition  to  those  already  mentioned,  the  princijjal  surgeons  were 
Guthrie,  Green,  Lloyd,  South,  Morgan,  Stanley,  and  Hawkins. 

George  James  Gutlirie  (1785-1850),  an  ap])rentice  of  a  London  sur- 
geon, was  appointed  hospital  mate  in  the  army,  and  sent  to  the  York 
Hospital  at  Chelsea  when  he  was  only  fifteen  years  old.  He  became 
assistant  surgeon  in  1801,  accompanied  his  regiment  to  North  America 
in  1806,  and  served  during  the  War  of  the  Peninsula  in  Spain,  becom- 
ing surgeon  of  the  forces  in  1810,  and  commanding  three  divisions  of 
cavalry  at  the  battle  of  Albuera.  He  was  placed  on  half  pay  in  1814, 
and  went  to  the  battle  of  Waterloo,  wliere  he  pcrfdrmed  an  amputation 
at  the  hip-joint  on  a  Freiiclnnan,  and  tied  both  ends  of  the  peroneal 
artery,  being  successful  in  each  case.  He  became  assistant  surgeon  to 
the  Westminster  Hospital  in  1823,  surgeon  to  the  same  hospital  in  1827, 
and  professor  of  anatomy  at  the  Royal  College  of  Surgeons  in  1828. 
His  treatise  On  gunKliot  wounds  of  tlic  e.vtremitics  rerjuirinr/  the  differ- 
ent operations  of  ainpntations,  etc.,  1815,  urging  prompt  amputation, 
marks  an  e])och  in  the  history  of  military  surgery  ;  the  sixth  edition, 
including  additions  relating  to  the  Crimean  War,  was  printed  in  1855. 
In  addition  to  this  he  published  A  treatise  on  the  operations  for  the 
formation  of  an  artificial  pupil,  etc.  (1819),  Lectures  on  the  operative 
surgery  of  the  eye  (1823  ;  3d  ed.  1838),  and  On  injuries  of  the  head 
affecting  the  brain  (4to,  1842  ;  2d  ed.  1847).  He  also  contributed  many 
papers  to  medical  journals. 

Joseph  Henry  Green  (1791-1863),  a  nephew  and  pnjiil  of  Henry 
Cline,  became  surgeon  to  St.  Thomas's  Hosjiital  in  1820  and  professor  of 
surgery  in  King's  College  in  1830.  In  1837  he  resigned  his  professor- 
ship, and  in  1852  his  position  at  St.  Thomas's.  His  publications  were 
chiefly  short  papers  in  medical   journals. 

Eusebius  Arthur  I^loyd  (1795-1862),  a  jjupil  of  Abernethy,  became 
assistant  surgeon  to  St.  Bartholomew's  in  1824,  and  surgeon  in  1847, 
from  which  position  he  retired  in  1861.  He  gained  the  Jacksonian 
prize  for  1818  by  his  essay  on  scrofula,  enlarged  and  published  in  1821. 

John  Flint  South  (1797-1882),  an  apprentice  of  Henry  Cline,  was 
admitted  as  a  member  of  the  Koyal  College  of  Surgeons  in  1819,  after 
which  he  studied  in  CJermany,  and  on  his  return  became  demonstrator  at 
St.  Thomas's  Hospital,  then  lecturer  on  surgery,  and  ultimately  surgeon 
to  the  hospital.  He  is  best  known  by  his  translation  of  Chclius's  Sys- 
tem of  surgery,  to  which  he  added  a  large  number  of  notes,  greatly  in- 
creasing the  value  of  the  work.  He  also  collected  materials  for  a  His- 
tory of  the  craft  of  surgery  in  England,  which   was  published   in   1886, 

Vol.  I.— 7 


98  TlIK  HISTORY  AND  LlTKUATinE  OF  SURdKllY. 

after  liis  dciitli,  under  the  Bupervision  of  Mr.  D'Arcy  Power,  and  is  a 
valuable  hook  of  reference.  Tiii'oiiiili  liis  eif'orts  tlie  remains  of  John 
Hunter  were  transferred  to  Westminster  Abbey,  and  the  inseri[)tion  on 
the  tablet  is  from   his  j)en. 

John  Morgan  (171*7-1847),  a  pupil  of  Astley  Cooper,  assisted  ]\Ir. 
Key  as  demonstrator  of  anatomy  in  a  private  school,  was  in  1821 
ap])ointed  assistant  surgeon,  and  in  1824  surgeon,  to  Guy's  Hos})ital,  in 
the  school  of  which  he  leetureil  on  anatomy  and  surgerv.  In  the  latter 
part  of  his  career  he  devoted  himself  to  ophthalniologv.  He  was  an 
excellent  operator,  ligated  the  iliac  artery  several  times,  was  one  of  the 
first  to  perform  fiap-amputations,  and  was  the  first  to  use  metal  sutures 
in  wounds  ;  he  was  also  one  of  the  first  to  perform  ovariotomy.  His  prin- 
cipal work  was  Lectures  on  diseases  of  the  eye  (1839).  He  also  assisted 
Dr.  Adtlison  in  An  Essay  on  the  operation  of  poisonous  ayents  in  the 
lirinij  hody  (1829). 

Edward  Stanley  (1791-1802)  studied  at  St.  Bartholomew's,  to  which 
he  became  assistant  surgeon  in  1816  and  surgeon  in  1838.  He  was 
twice  president  of  the  Royal  College  of  Surgeons.  His  jirincipal  publi- 
cation was  A   Treatise  on  the  diseases  of  the  bones  (1849). 

Cjesar  H.  Hawkins  (1798-1884),  prosector  of  anatomy  in  the  school 
of  Great  ^\'indmill  Street  for  many  years,  became  surgeon  of  St. 
George's  Hospital  in  1829,  and  retired  in  18(]1.  In  1801  he  was  presi- 
dent of  the  Royal  College  of  Surgeons,  and  in  1862  Serjeant  surgeon  to 
the  queen,  succeeding  Brodie,  being  the  fourth  of  his  family  to  hold 
this  position.  His  works  were  collected  and  pul)lished  in  two  volumes 
in  1874. 

Among  the  distinguished  provincial  surgeons  of  the  century  were 
George  Freer  of  Bii'mingham,  author  of  Observations  on  aneurism  and 
some  diseases  of  the  arterial  system  (4to,  1807) ;  Joseph  Hodgson  of 
Birmingham,  best  known  by  his  treatise  on  Diseases  of  the  arteries  and 
veins  (London,  1815;  translated  into  French  and  German);  John  H. 
James  (1789-1869)  of  Elxeter,  the  author  of  the  Jaeksonian  ])rize  essay 
for  1818  on  inflammation,  and  the  second  to  ligate  the  abdominal  aorta; 
John  Green  Crosse  (1790-1  SoO)  of  Norwieh,  author  of  the  Jaeksonian 
prize  essay  for  1825  on  urinary  calculus,  and  whose  fine  librar}'  on 
diseases  of  the  urinary  organs  came  into  the  possession  of  Professor 
S.  D.  Gross,  and  was  destroyed  by  fire  in  Louisville ;  John  Gay 
(1791—1870)  of  Swindon,  a  pupil  of  Abernethv  ;  John  Smith  Soden 
(1780-1863)  of  Bath  ;  George  M.  Jones  (180?-iS61)  of  Jersey,  a  bril- 
liant operator,  who  performed  excision  of  the  knee-joint  without  know- 
ing of  Fergusson's  operation  a  few  weeks  before,  excised  the  hij)  and 
ankle-joints,  extirpated  the  scapula,  etc.;  William  Sands  Cox  (1802-76), 
one  of  the  founders  of  tlie  Birmingham  School  of  Medicine  in  1828, 
author  of  ]\[einoir  an  amj/uftition  of  the  thif/h  at  the  hip-joint  (1845) ; 
Thomas  Pridgen  Teale  (1801-68),  fi.under  of  the  Leeds  School  of  Med- 
icine, author  of  A  jjractica/  treatise  on  (dtdniniiiaf  liernia  (184(5;  trans- 
lated into  German  1848,  and  into  Dutch  1849),  and  best  known  by 
his  work.  On  amputation  by  a  lonr/  and  short  rectangular  flap  (1858) ; 
Joseph  Jordan  (1786-1873)  of  Manchester,  the  first  provincial  lecturer 
on  anatoni)'  and  surgery  whose  certificates  were  recognized  by  the  Royal 
College  of  Surgeons  (in   1821),  fi)under  of  the  liock  Hospital  in  1819, 


THE  HISTORY  AXD  LITERATURE  OF  SURGERY.  99 

ami  surjifon  of  tlie  Mancliestcr  Infirnuuy  after  18.'55;  George  Sontliani 
(1815-70)  of  Manchester,  founder  of  the  Cliathara  Street  School  of 
Medicine  in  1850,  surgeon  to  the  Royal  Infirmary  in  1855,  and  professor 
of  surgery  in  Owens  College  on  its  foundation  in  1872,  author  of  He- 
(/ional  surgery  (3  parts,  1882-86) ;  and  Josepli  Sampson  Gamgee  (1828- 
86),  the  son  of  a  veterinary  surgeon,  wlio  studied  at  University  Col- 
lege, London,  and  after  graduation  studied  at  Paris,  Pavia,  and  Flor- 
ence. In  1857  Gamgee  was  appointed  surgeon  to  the  Ciueen's  Hospital 
at  Birmingham,  which  position  he  retained  until  1881,  becoming  one  of 
the  most  distinguisluHl  provincial  surgeons  of  England.  He  was  a  bril- 
liant operator  and  a  tiuent  speidvcr.  He  urged  the  dry,  infre(juent  dress- 
ing of  wounds.  His  principal  publications  are — ( )n  tlic  adranfagcx  of 
the  starched  appdrctux  in  (he  treatincut  fjf  frarfures  and  diseases  of  Joints 
(1853),  Researches  in  pathological  anatomy  and  clinicnl  sure/ery  (1856), 
On  the  treatment  of  fractures  of  the  limbs  (1871),  and  On  the  trerdment 
of  wounds  (1878). 

The  leading  Dublin  surgeons  during  the  century  were  Golles,  Crani])- 
ton,  Carmichacl,  Porter,  (_'us;ick,  Adams,  Harrison,  Bellingham,  Smith, 
anil  Tufncll. 

Abraham  Colics  (177a-184.j)  graduated  at  Edinburgh  in  1797,  and  in 
1804  became  professor  of  surgery  in  Dublin,  which  position  he  held  for 
thirty-two  years,  and  for  twenty  years  was  the  chief  of  the  Irish  sur- 
geons. His  name  remains  connected  witJi  the  form  of  fracture  of  the 
carpal  extremity  of  the  radius  descril)ed  by  him  in  the  Edinb.  Med,  and 
Surf/.  Journid  (1814),  and  with  the  so-callt'd  "Colics'  law" — /.  e.  that  a 
mother  infected  with  syphilis  through  the  ftetus  acquires  a  certain  degree 
of  immunity  and  will  not  suffer  by  suckling  the  infant.  In  1816  he 
first  tied  the  subclavian  within  the  scaleni.  His  princijial  surgical 
pul)lications  are  a  treatise  on  surgical  anatomy  (1811)  and  Lectures 
on  the  theory  and  practice  of  surgery  (2  vols.,   1844-45). 

Sir  Philij)  Crani])ton  (1777-1858),  a  native  of  Dul)lin,  was  appointed 
surgeon  to  tlie  Mcath  Hospital  when  twenty-one  years  old,  and  was  one 
of  the  founders  of  the  first  private  school  for  anatomy  and  surgery  in 
Dublin.  He  was  a  skilful  operator  and  an  eloquent  lecturer,  and  con- 
tributed numerous  ])apers  to  medical  journals. 

Kichard  Carmichacl  (1779-1849),  a  native  of  Dublin,  but  of  Scotch 
descent,  passed  his  examination  as  assistant  surgeon  wlicn  seventeen 
years  old,  and  in  1803  settled  in  Dublin  and  was  apj)ointed  surgeon  to 
St.  George's  Hospital.  In  1826  he  was  one  of  the  founders  of  the 
Kichniond  School  of  Medicine,  giving  lectures  on  surgery,  and  was  very 
])rominent  in  the  various  medical  associations  of  his  time.  He  be- 
(pieathcd  to  the  College  of  Surgeons  in  Ireland  the  sum  of  £3000,  the 
interest  of  which  was  to  be  used  in  giving  ])rizcs  every  four  years  for  the 
best  essays  on  the  state  pf  the  medical  profession  in  Great  Britain  and 
Ireland,  and  these,  known  as  the  Carmichacl  prize  essays,  are  valuable 
historical  documents.     His  principal  works  relate  to  venereal  diseases. 

William  Henry  Porter  (1790-1861),  a  ])U])il  of  Mr.  Crampton,  was 
elected  surgeon  to  the  Meath  Hos])ital  in  1819,  and  in  1836  succeeded 
Colles  as  ])rofessor  of  surgery  in  the  Royal  College  of  Surgeons.  He 
was  a  bold  ojierator,  an  chxpient  lecturer,  and  an  excellent  teacher. 
Besides  a  number  of  important   papers  in  the  journals,  he  published 


100  THE  HISTORY  AND  LITERATURE  OF  SURGERY. 

Observations  on  the  surr/leni  pafhofor/i/  of  the  larjpix  and  trachea  (182G  ; 
2d  ed.  1837),  a  classical  work. 

James  William  ( "iisa('k(l 787-1  SIJl ),  sura-cdn  to  Stcvi'iis's  and  Swift's 
hosj)itals,  was  in  18/32  elected  to  the  prot'cssorship  of"  surgery  in  the 
University  of"  Dublin,  founded  that  year,  and  was  three  times  president 
of  the  College  of  Surgeons.  He  was  a  bold  and  skilful  oj)erator,  trained 
many  pupils,  and  enjoyed  the  entire  confidence  of  his  ])rofessional  brethren. 
He  contributed  some  pa])ers  to  periodicals,  liut  wrote  no  S])ecial  work. 

Robert  Adams  (1791-1873),  surgeon  to  the  Jervis  Street  and  the 
Richmond  hospitals,  was  one  of  the  founders  of  the  Hiciunoud  (or,  as  it 
was  afterward  called,  the  Carmicliael)  School  of  Medicine,  and  in  18G1 
was  appointed  Regius  professor  of  surgery  in  the  University  of  Dublin. 
His  principal  work  was  his  Treatise  on  rheumatic  gout,  or  chronic  rheu- 
matic arthritis  of  all  the  joints  (1857  ;  2d  ed.  1873). 

Robert  Harrison  (1796-1858),  a  native  of  Cuniljerland,  was  appren- 
ticed to  CoUes  in  1810,  took  the  degree  of  M.  B.  in  1824,  and  was 
ap])ointed  professor  of  anatomy  and  surgery  in  the  University  of  Dublin 
in  1S37.  His  principal  work  was  'The  surgical  anatomy  of  the  arteries 
(2  vols.,  1824-25). 

O'Bryen  Bellingham  (1805-57)  graduated  at  Edinburgh  in  1830,  and 
was  elected  surgeon  to  St.  Vincent's  Hos])ital  in  1835.  His  name  is 
especially  connected  with  the  treatment  of  aneurism  by  compression,  a 
method  which  was  systematized  and  made  popular  by  Dublin  surgeons, 
and  with  regard  to  which  his  little  book,  Obserrations  on  aneurysm,  and 
its  treatment  by  compression  (1847),  is  still  a  valualile  M-ork. 

Robert  William  Smith  (1807-73),  a  native  of  Dublin  and  an  appren- 
tice of  Richard  Carmicliael,  was  a  teacher  of  surgery  in  the  Richmond 
Hospital  School,  and  in  1849  was  appointed  the  first  j)rofessor  of  surgery 
in  the  School  of  Physic  of  the  Univei'sity  of  Dublin,  the  chairs  of 
anatomy  and  surgery  having  been  luiited  prior  to  that  date.  He  was 
eminent  as  a  teacher  and  as  a  skilled  pathologist,  was  for  thirty-five 
years  secretary  of  the  Dublin  Pathological  Society,  and  made  numerous 
and  valuable  contril)utions  to  surgical  literature.  His  principal  work  is 
A  treatise  on  fractures  in  the  ricinify  of  joints,  and  on.  certain  forms  of 
accidental  and  cone/enital  dislocations  (1847). 

Thomas  Jolliffe  Tufnell  (1819-75),  a  native  of  Chippenham,  Wilts, 
studied  in  London  under  Brodie  and  C^sar  Hawkins,  entered  the  army 
medical  service  in  1S41,  and  after  the  Crimean  War  retired  from  active 
service  and  settled  in  Dul)lin.  He  was  surgeon  to  the  City  of  Dublin 
Hospital  and  jirofessor  of  military  surgery  in  the  school  of  the  College 
of  Surgeons.  His  principal  ^\•orks  \vere — Practiced  remarks  on  the  treat- 
ment of  aneurism  by  compression  (1851)  and  The  successful  treatment  of 
internal  aneurism  (1864;  2d  ed.  1875). 

In  addition  to  those  already  mentioned,  and  excluding  those  yet 
living,  the  following  have  been  the  prominent  London  surgeons  since 
the  middle  of  the  century  : 

James  Luke  (1798-1881)  studied  at  the  London  Hospital,  where  he 
became  lecturer  on  anatomy  in  1823,  lecturer  on  surgery  in  1825,  and 
surgeon  to  the  hospital  in  1833,  which  position  he  resigned  in  1861. 
His  name  is  specially  connected  with  a  simplified  method  of  operation 
for  femoral  hernia. 


THE  HISTORY  AXD  LITERATURE  OF  SURGERY.  101 

Frederic  Carpenter  Skey  (1798-1872),  a  pupil  of  Abernethy,  was 
for  ton  years  lecturer  on  surgery  in  tlie  Aldcrsoate  School,  and  in  1843 
hecanie  professor  of  anatomy  at  St.  Ijartlidlninew's  Hospital,  to  which 
lie  iiad  been  elected  assistant  surgeon  in  1.S27,  and  where  he  became  sur- 
geon in  1854,  retiring  in  18G4.  His  principal  work  was  his  treatise  on 
Operative  surgeri/  (1850  ;  2d  ed.  1858). 

John  Hilton  (1804-78)  studied  at  Guy's  Hospital,  in  the  medical 
school  of  which  he  was  appointed  demonstrator  of  anatomy  in  1828, 
and  held  this  jjosition  for  fourteen  years,  being  reputed  to  lie  the  best 
anatomist  in  London.  In  1845  he  was  ajipointed  assistant  surgeon,  and 
in  1849  surgeon,  at  Guy's.  He  is  best  known  by  his  book  on  Bi'sf  and 
pain  (1863;  2d.  ed.  1877),  one  of  the  most  valuable  contributions  of 
the  century  to  surgical  literature. 

Edward  Cock  (1805-92),  nephew  and  pupil  of  Astley  Cooper,  was 
appointed  demonstrator  of  anatomy  in  Guy's  Hospital  medical  school 
on  its  foundation  in  1825,  assistant  surgeon  to  the  hospital  in  1838,  and 
surgeon  in  1848,  retiring  in  1871.  He  is  best  known  liy  his  papers  on 
puncture  of  the  bladder  through  the  rectum  (1852)  and  on  a  method  of 
opening  the  urethra  in  cases  of  impermeable  stricture  (1866). 

William  Coulson  (1802-77),  a  pupil  of  Tyrrell,  studied  in  Berlin  for 
two  years,  and  on  his  return  was  associated  with  Tyrrell,  Jones,  Quain, 
Lawrence,  and  Wardrop  in  the  medical  sciiool  in  Aldersgate  street,  in 
which  he  taught  anatomy.  At  the  same  time  he  was  on  the  editorial 
stati"  of  The,  Lancd.  In  1851  he  was  elected  surgeon  to  St.  Mary's  Hos- 
pital.    His  jjrincipal  works  relate  to  diseases  of  the  urinary  organs. 

Henry  Hancock  (1809-80)  studied  under  Guthrie,  became  demon- 
strator of  anatomy  at  the  Westminster  Hospital  School  in  1835,  and  in 
1839  assistant  surgeon  at  Charing  Cross  Hospital,  where  he  succeeded 
to  the  lectureship  of  surgery  on  the  death  of  Mr.  Howship  in  1841. 
His  principal  work  was  On  the  operative  surgery  of  the  foot  and  ankle- 
joint  (ISl^i). 

Thomas  Blizard  (1811-88),  a  native  of  London  and  nephew  of  Sir 
William  Blizard,  became  assistant  surgeon  to  the  London  Hospital  in 
1833  and  surgeon  in  1849,  from  which  position  he  retired  in  1869.  His 
principal  jtuhlications  vtcre — A  Treatise  on  tetanus  (Jacksonian  prize 
essay,  1836),  Practiced  treatise  on  tlie  diseases  of  the  testicle,  spermcdic 
cord,  etc.  (L(jndon,  1843  ;  4th  ed.  1878),  and  Observations  on  the  diseases 
of  the  recfuin  (London,  1851  ;  4tli  ed.  1876).  He  contributed  a  number 
of  very  valuable  papers  to  the  Medico-chirurgictd  Transactions,  including 
his  "  Improved  observations  on  acute  ulcerations  of  the  duodenum  in 
cases  of  burn"  (1842). 

Campl)ell  de  Morgan  (1811-76),  a  younger  brother  of  the  mathema- 
tician, Augustus  de  Morgan,  and  a  pupil  of  Sir  Charles  Bell,  studied  at 
LTniversity  College,  and  in  1842  was  elected  assistant  surgeon  to  the  Mid- 
dlesex Hospital,  becoming  full  surgeon  in  1848.  In  1866-67  he  became 
joint  lecturer  on  surgery  with  IVIr.  Shaw.  He  contributed  to  Holmes's 
System  of  surgery  and  some  papers  to  periodicals,  and  published  The 
ori(/in  of  cancer  considered  with  reference  to  the  treatment  of  the  disease 
(1872). 

John  Gay  (1813-85)  studied  in  London,  and  in  1836  became  surgeon 
to  the  newly-established  lloyal  Free  Hospital.     In  1856  he  was  surgeon 


102  THE  HISTORY  AM)   LITERATURE  OF  SURGERY. 

to  the  Cirt'tit  Nortlicrii  Hosijital.  His  principal  works  arc — On  femoral 
rupture  (1848)  and  (Jit  vnricom  veins  (18(J.S).  He  must  not  be  con- 
founded witli  Jdlm  (iay  (1791-1870),  a  distinjrnislicd  siiryicon  at  Rwindon 
and  a  pii])il  of  Ahcrnctliy,  wlio  uradnatcd  in  1  Sll ,  or  witii  liis  son  ot'tlic 
same  name,  who  died  at  Swindon  in  llSfiit. 

Kobert  Drnitt  (18]4-8o)  was  not  cc^nncctcd  w  itii  any  liospital  and  cHd 
not  pi-actise  surgery,  but  his  Vdde  Meciim,  the  first  edition  of  wliich  ap- 
l)eared  in  1838  and  contained  the  teaehinjis  of  Green  and  of  Joseph 
Henry,  met  with  great  favor,  reaching  its  eleventh  edition  in  1878  and 
a  sale  of  forty  thousand  copies. 

Kiciiard  Holmes  C'oote  (1817-72),  a  }>upil  of  Sir  William  Lawrence, 
l)ccame  demonstrator  of  anatomy  at  St.  Bartholomew's  in  1846,  assistant 
surgeon  to  the  hos])ital  in  1852,  and  surgeon  and  lecturer  on  surgery  in 
1863.  He  contributed  many  ])aj)ers  to  journals  and  transactions,  and  is 
best  known  by  his  treatise  On  joint  (Jiseascx,  jjublished  in  1867. 

John  Marshall  (1818-91),  a  student  and  assistant  of  Liston,  became 
siu-geon  of  University  College  Hospital  and  professor  of  surgery,  in 
which  position  he  gave  sjiecial  attention  to  physiology  and  pathology 
and  to  the  views  of  Virchow,  C'ohnheim,  and  other  German  authorities. 
During  the  latter  part  of  his  life  he  was  president  of  the  General  Medical 
Council.  His  principal  published  work  was  his  Outlines  of  phymology 
(2  vols.,  1867). 

Alfred  Poland  (1822-72),  a  pupil  of  ]\Ir.  Aston  Key,  became  dem- 
onstrator of  anatomy  at  Guy's  Hos])ital  in  1845,  assistant  surgeon  of 
the  hospital  in  1849,  and  full  surgeon  in  1861.  His  Essay  on  gunshot 
wounds  and  their  treatment  received  the  Jacksonian  prize  at  the  College 
of  Surgeons,  and  his  paper,  Tlie  injuries  and  wounds  of  the  abdomen, 
gained  for  him  the  Fotherg-illian  medal  of  the  Medical  Society  of  Lon- 
don.  He  contributed  many  papt'rs  to  Guy's  Hospital  Reports  and  also 
to  the  weekly  medical  journals,  but  wrote  no  important  separate  work. 

John  Cooper  Forster  (1823-86),  the  son  of  a  medical  man,  studied  at 
Guy's,  where  in  1850  he  was  ap])ointed  demonstrator  of  anatomy,  in 
1855  assistant  surgeon,  and  in  1870  surgeon,  which  latter  position  he 
resigned  in  1880.  He  performed  the  first  gastrostomy  in  England  in 
1858.  His  only  pul)lished  separate  work  was  on  The  sun/ieal  diseases 
ofrhifdren  (1860). 

George  William  Callender  (1830-79)  studied  at  St.  Bartholomew's, 
where  he  became  assistant  surgeon  in-  1861,  surgeon  in  1871,  and  lec- 
turer on  surgery  in  1873.  He  contril)uted  largely  to  St.  Bartholomew's 
Hospittd  Beports,  o{  which  he  was  surgical  editor  from  1865  to  1873, 
and  also  furnished  many  papers  and  notes  of  clinical  lectures  to  journals 
and  transactions.  The  Transactious  of  the  Royal  iSoeiety  i'or  1869  con- 
tain an  important  i)aper  by  him  on  "  The  formation  and  growth  of  the 
bones  of  the  human  face."  He  \\as  one  of  the  first  to  carry  out  in  detail 
asepsis  in  surgery,  as  contradistinguished  from  antisepsis.  His  only 
separate  work  was  Anatomy  of  the  parts  concerned  in  femoral  rupAure 
(1863). 

Peter  Charles  Price  (1832-64),  the  son  of  a  physician,  studied  at 
King's  College,  and  became  assistant  to  Mr.  Fergusson  in  1854.  He  was 
appointed  assistant  surgeon  to  King's  College  Hospital  in  1861.  He 
paid  special  attention  to  the  pathology  and  surgery  of  the  joints,  and  more 


THE  HISTORY  AXH  LITERATURE  OF  SURGERY.  103 

espt'c'ially  to  tlie  diseases  of  the  knee  and  their  treatment  hy  excision. 
His  principal  M-ork  is  .4  Description  of  the  diseased  conditiuim  of  the  knee- 
joint  wltieh  require  amputation  of  the  limb,  and  those  conditions  u^hich  are 
favorable  to  excision  of  the  joint,  etc.,  pnl)lisiied  after  his  death  in  18(55. 

Charles  Frederick  Maunder  (18:32-7!l)  studied  in  Bristol,  London, 
Edinburgli,  and  Paris,  served  in  the  army  dnrino-  tlie  Crimean  War,  and 
was  appointed  assistant  surgeon  to  the  London  Hospital  in  l!S()(),  and 
surgeon  in  1869.  He  was  a  bold  and  skilful  operator,  and  his  text-book 
on  operative  surgery  (1860;  2d  ed.  1873)  was  an  excellent  manual. 

"William  Frederick  Teevan  (1833-87)  was  educated  at  University 
College,  and  was  elected  assistant  surgeon  of  the  West  Ijondon  Hos- 
pital for  Urinary  Diseases  in  1866,  after  which  he  devoted  himself 
more  especially  to  the  surgery  of  the  genito-urinary  organs.  He  is  best 
known  by  his  work.  Inquiry  into  the  cuus(dion,  diagnosis,  and  treatment 
of  fractures  of  the  internal  table  of  the  skidl  (1864),  which  is  a  classical 
work  of  reference  on  this  subject. 

Marcus  Beck  (1843-93)  studied  at  Glasgow  under  Mr.  Joseph  Lister, 
his  cousin,  and  at  University  College,  Ijondon,  and  in  1873  was  a])pointed 
assistant  surgeon  to  University  College  Hospital,  becoming  surgeon  in 
1885  and  lecturer  on  surgery  in  the  same  year.  He  was  one  of  the  first 
to  introduce  antiseptic  methods  in  surgery  in  London,  and,  though  not  a 
voluminous  writer,  made  some  valualile  contriliutions  to  surgical  litera- 
ture, including  a  paper  on  "  Consecutive  nephritis,"  or  surgical  kidney, 
in  Reynolds's  Si/.stem  of  medicine,  and  a  jjart  of  the  report  on  pvitmia 
and  septicemia  in  the  Transactions  of  the  Patholof/icul  Society  for  1879. 

Frederick  LeGros  Clark  (1811-92),  an  apprentice  of  Travers,  stud- 
ied at  St.  Thomas's  Hospital,  beginning  in  1.S27,  and  was  appointed 
assistant  demonstrator  of  anatomy  in  1830.  In  1839  he  became  lec- 
turer on  anatomy  and  ])hysiology,  in  184.'>  assistant  surgeon  to  the  hos- 
pital, and  in  1853  full  surgeon,  which  office  he  retained  for  twenty  years. 
When  ^Ir.  St)utli  resigned  the  chair  of  surgery  Mr.  Clark  succeeded  him, 
and  retained  the  office  until  he  retired  from  the  hospital  in  1873.  His 
principal  work  was  his  Lectures  on  the  jvinciples  of  surgical  diagnosis : 
e.speci(dfy  in  relation  to  sitock  and  visceral  lesions  (London,  ]S7t);  2d 
ed.  1872).  A  numlier  of  his  papers  in  journals  and  addresses  were 
collected  and  printed  under  the  title  of  Papers  on  surgery,  pathology, 
and  allied  subjects  (8vo,  London,  1889). 

The  two  greatest  advances  in  surgery  in  the  nineteenth  century  are 
the  introduction  of  aniesthetics,  which  was  due  to  American  surgeons, 
and  will  l)e  referred  to  hereafter,  and  the  introduction  of  systematic  and 
scientific  antisepsis  and  asepsis  in  the  treatment  of  wounds  and  the  per- 
formance of  surgical  operations,  which  is  due  to  an  P]nglish  surgeon. 
Sir  Joseph  Lister,  who  brought  it  into  notice  in  1867-68.  Antiseptics 
<3f  variinis  kinds  had  been  proposed  and  used  by  others  prior  to  this 
date.  Kiichenmeistcr  'of  Dresden  had  reported  good  results  from  the 
use  of  carbolic  acid  in  1860  ;  Lemaire's  work  on  carbolic  acid  ap])eared 
in  1863;  Cam|)bell  de  Morgan  used  chloride  of  zinc  in  1866;  but  it 
was  Mr.  Lister  who  established  the  method  on  the  basis  of  Pasteur's 
ex|K'riments  showing  that  putrefaction  is  due  to  the  action  of  micro- 
orgiuiisms,  and  who  systematically  sought  for,  and  found,  means  to  jire- 
vent  the  access  of  these  micro-organisms  to  wounds  or  to  destroy  their 


104  THE  insTonr  and  litehatt're  of  ST'naEnY. 

vitality  if  tliov  had  already  j^aiiicd  adiiiissidti,  and  to  do  tliis  with  tlie 
least  po8sil)le  injuiy  to  tlic  li\iii<;'  tissues.  The  aetual  eauterv  and  tiie 
boiling  oil  of  the  surgeons  of  the  tifteenth  and  prior  centuries  were 
antiseptic,  no  doubt,  as  were  also  some  of  the  multifarious  wound-dress- 
ings in  use  since  the  days  of  Hippocrates ;  but  antiseptic  surgery  began 
with  Mr.  Lister,  and  its  progress  has  lieen  largely  due  to  the  scientific 
manner  in  which  he  ileveloped  and  expounded  it.  A\'ith  tlie  introduc- 
tion of  Koch's  method  of  t'lilturcs  on  solid  or  scnii-solid  media,  wliich 
is  the  fcnindation  of  the  new  bacteriology,  has  come  a  knowledge  of  the 
mode  of  development  and  of  the  results  of  the  growth  of  some  of  these 
organisms  which  has  already  revolutionized  operative  surgery,  and 
made  obsolete  and  com])aratively  useless  a  vast  amount  of  surgical 
literature  and  statistics.  An  illustration  of  this  is  given  in  a  compari- 
son of  the  results  obtained  by  Liston  in  1S44  with  those  olitained  in  the 
University  College  Hos])ital  forty  years  later,  contained  in  an  address  on 
surgery  by  John  Marshall  in  the  British  Medical  Journal  (August  8, 
1885,  p.  235).  He  concludes  that  "injuries  not  involving  a  breach  of 
the  surface  of  the  body,  simple  intlammations  consecutive  to  these,  or  so- 
called  idiopathic  local  intlanuuations  whicli  come  under  the  care  of  the 
surgeon,  such  as  sprains,  simple  dislocations,  synovitis,  orchitis,  and 
other  cases,  were  not  less  satisfactorily  treated  in  1844-45  than  in  1883, 
and  the  progress  of  the  patients  toward  recovery  was  quite  as  rapid,  but 
that  in  eases  of  wounds  and  operations  the  diifcrence  in  fa\-or  of  the 
latter  period  is  very  striking." 

After  the  abolition  of  the  medical  faculties  and  societies  iri  France  by 
the  decrees  of  1792  and  1703  the  evil  results  of  want  of  means  for  giv- 
ing proper  medical  instruction  soon  became  evident  from  the  fact  that 
properly-qualified  medical  officers  could  not  be  found  to  supply  the 
jilaces  of  those  who  died  in  the  service  of  the  armies  of  the  Rejiublic. 
By  direction  of  the  National  Convention  a  report  was  prejiared  by  the 
celebrated  chemist,  Fourcroy,  on  the  best  plan  of  organizing  medical 
schools  to  meet  this  want,  and  in  accordance  with  this  report  a  law  was 
passed  in  1794  establishing  medical  schools  at  Paris,  ]\Iontpellier,  and 
Strasburg.  The  method  taken  to  secure  students  was  peculiar  and  effec- 
tual. From  each  district  in  France  a  young  man  between  seventeen 
and  twenty-six  years  of  age,  whose  name  had  not  been  drawn  in  the  first 
conscription,  was  selected  Ijy  the  governmental  authorities  and  forwarded 
at  the  expense  of  the  State  to  one  of  these  schools,  three  hundred  being 
assigned  to  Paris,  one  hundred  and  fifty  to  Montpellier,  and  one  hundred 
to  Strasburg.  Three  years  was  the  period  of  instruction  alkiwed,  and  as 
soon  as  they  were  considered  qualified  they  were  sent  to  join  the  troops. 
These  were  really  military  medical  schools  analogous  to  that  established 
at  Berlin.  They  did  not  confer  the  doctor's  degree,  the  object  being 
simply  to  manufacture  medical  officers  as  soon  as  possible. 

After  several  changes  the  Paris  school  was  definitely  organized  in 
1804,  and  became  a  medical  society  as  well  as  a  teaching  body,  the 
object  of  the  government  being  to  obtain  not  only  a  medical  faculty, 
but  a  scientific  body  which  should  be  capable  of  giving  advice  to  the 
government.  The  society  part  of  this  arrangement  was  dissolved  in 
1821  by  the  formation  of  the  Academy  of  ]\Iedicine. 

In  1806  the  Imperial  University  was  created,  and  in  1808  the  med- 


THE  HISTORY  ASD  LITERATURE  OF  SURGERY.  105 


ical  school  became  its  faculty  of  medicine.  In  1822,  owing  to  political 
trouljles,  the  Faculty  of  Medicine  was  suppressed,  but  it  was  re-estal)- 
lished  in  182;^  with  a  change  in  a  number  of  the  professoi's,  A.  Duljois 
and  Pelletan  losing  their  chairs. 

In  1830  the  Faculty  of  IMedieine  was  again  reorganized,  the  acts 
of  1822  and  1823  being  abolished  and  the  old  professors  being  again 
placed  in  their  chairs,  while  at  the  same  time  the  concours  was  again 
estal)lished  as  a  means  of  tilling  the  professorships.  Jules  Rochard,  in 
his  Hisfnirc  fJc  la  ehinnyic  fraiujatse  an  .rl.v'  siec/c  (Paris,  1875),  gives 
the  most  complete  and  satisfactory  account  of  French  surgery  of  the 
century,  and  his  division  of  it  into  four  periods  will  be  followed  in  tliis 
sketch. 

At  the  beginning  of  the  century  the  leading  surgeons  in  Paris  were 
Sabatier,  Deschamjis,  Lassus,  Boyer,  Dubois,  Pelletan,  and  Lallement. 
Sabatier  and  Deschamps  have  already  been  referred  to  in  speaking  of 
French  surgeons  in  tiie  latter  part  of  the  eighteenth  century. 

Pierre  Lassus  (1741-1807),  pi'ofessor  of  surgery  in  the  £cole  de 
Sant6  and  consulting  surgeon  of  Napoleon  I.,  was  a  learned  surgeon  who 
was  the  author  of  a  good  history  of  anatomy,  of  a  manual  of  operative 
surgerv  (2  vols.,  Paris,  1794),  and  of  Pathologic  clururf/ica/e  (2  vols., 
Paris,"  1805-0(3). 

Alexis  Boyer  (1757-1 833)  was  a  pupil  of  Desault  and  surgeon  of  the 
Charite,  a  modest,  quiet,  studious,  hard-working  man,  without  much 
originality  or  brilliancy  either  in  his  clinical  work  or  his  lectures  and 
writings,  but  a  careful  compiler  and  a  thoroughly  reliable  teacher.  His 
Traite  den  iiudarJien  chirun/icalcs  (11  vols.,  l.S14-2(j)  is  a  practical  svs- 
tem  of  surgerv,  the  must  complete  of  its  kind  then  in  existence,  and  for 
many  years  it  remained  the  highest  authority  in  this  branch  of  medical 
literature.  His  chief  contributions  to  practical  surgery  were  his  descrip- 
tions of  the  painful  crepitation  of  tendons,  of  translucency  of  the  tumor 
as  diagnostic  in  hydrocele,  of  bleeding  fungous  tumors,  and  of  the  com- 
plications of  fissure  of  the  anus.  His  system  is  ciiaracterized  by  Mal- 
gaigne  as  a  sununary  of  the  works  and  opinions  of  the  French  Academv 
of  Surgery,  which  is  no  doubt  correct.  It  is  a  resume  of  French  sur- 
gery which  he  gives,  and  he  has  little  or  nothing  to  say  of  the  surgery 
of  Germany,  of  England,  or  of  America. 

Antoine  Dubois  (1756-1837),  a  pupil  of  Desault,  professor  of  anat- 
omy in  the  ftcole  de  Sante,  was  a  skilful  surgeon  and  a  good  clinical 
teacher,  but  wrote  nothing  of  imj)ortance. 

Philippe  Jean  Pelletan  (1747-1829),  a  pupil  of  Louis  and  of  Sabatier, 
succeeded  Des;udt  as  chief  surgeon  at  the  Hotel  Dieu,  became  professor 
of  clinical  surgery  at  the  founding  of  the  Medical  Faculty  of  Paris,  and 
consulting  surgeon  to  the  emperor.  In  1815  he  was  professor  of  o])era- 
tive  surgerv,  and  retired  from  ])ractice  in  1823.  He  was  an  eloquent 
lecturer,  but  made  no  valuable  contributions  to  the  art.  His  C Unique 
chirurr/irafe  ('■'>  vols.)  was  pul>lislied   in    1810-11. 

Andre  Marie  Lallement  (1750-1830),  a  pupil  of  Desault,  was  surgeon 
to  the  Salpetriere  anil  professor  of  surgery  in  the  Medical  Faculty.  He 
wrote  only  a  few  papers  for  periodicals. 

To  these  should  be  added  the  names  of  Larrey,  Percy,  Dufouart,  and 
Siuicerotte. 


10()  THE  HISTORY  AND  LITERATURE  OF  SURGERY. 

Dominique  Jean  Larrey  (17(50-1842),  the  most  distinguishod  military 
surgeon  at  the  end  of  tiio  last  an<l  the  beginning  of  the  present  eentury, 
served  in  the  Napoleonic  campaigns,  and  was  professor  in  the  military 
school  founded  in  179(j  at  Val-de-Grace.  His  chief  writings  are  his 
3I('inoiirs  de  medcc'uu'  ini/itaire  ct  campagnes  (4  vols.,  Paris,  LSI 2-1 7) 
and   his  liecueil  de  'inemoiir><  fJe  cliirtiiyie  (Paris,   1821). 

Pierre  Francois  Percy  (1754—1825)  was  professor  in  the  military 
medical  school  in  1820.  At  his  suggestion  a  battalion  of  litter-bearers, 
or  a  hospital  corps,  was  created  in  the  Italian  war. 

To  the  second  period  (1814-;}5)  belong  Dupuytren,  Richerand,  Roux, 
Marjolin,  Lisfranc,  Sanson,  and  Jules  (_'lo(|uet. 

<Tuillaume  Dupuytren  (1778-ls;55)at  the  age  of  eighteen  obtained  by 
concours  a  ])osition  as  prosector  in  the  Academy,  in  1801  became  chief 
of  the  department,  in  1808  obtained  a  place  on  the  surgical  staff  of  the 
Hotel  Dieu,  in  1812  was  appointed  to  the  chair  of  operative  surgery,  and 
in  1815  became  surgeon-in-chief  to  the  Hotel  Dieu.  For  the  next  fifteen 
years  he  was  the  most  distinguished  surgeon  in  France — and,  for  that 
matter,  in  the  world,  as  tiie  fame  of  his  clinical  teacliiug  drew  crowds  of 
.students  from  all  countries.  His  studies  in  pathological  anatomy  and  in 
experimental  physiology  contributed  greatly  to  his  success,  which  turned 
largely  on  his  unequalled  jiowers  f)f  diagnosis. 

He  was  not  a  student  of  books,  and  wrote  but  little,  and  that  little  is 
not  remarkable.  He  made  no  great  discoveries,  his  chief  contrilmtions  to 
the  art  being  his  method  of  treating  artificial  anus  by  means  of  his  com- 
pressing enterotome,  his  excisions  of  the  jaws,  and  the  subcutaneous 
section  of  the  sterno-mastoid.  He  was  a  cold,  i-eserved,  unscrupulous, 
and  ambiti(jus  man,  Avith  contemptuous  and  oftensive  manners,  who  can 
hardly  be  said  to  have  had  any  personal  friends;  but  he  was  an  incessant 
worker,  thoroughly  self-reliant,  a  bold  operator,  and  unsurpassed  as  a  clin- 
ical teacher  in  the  jirecision,  method,  and  clearness  with  which  he  stated 
all  the  salient  points  of  the  case  on  hand.  His  clinical  lectures  were 
noted  and  published  by  Brierre  de  Boismont  and  Buet  in  1832-34  in  4 
volumes  ;  a  second  edition,  in  6  volumes,  appeared  in  1839.  Those  por- 
tions of  these  lectures  which  relate  to  injuries  and  diseases  of  the  bones 
were  translated  by  F.  Le  Gros  Clark  and  pul)lislie(l  by  the  Sydenham 
Society  in  1847  ;  and  other  selections,  under  the  title  of  On  /t'.s/o/(.s  of  tlie 
rancular  sysfein,  di.seascs  of  the  rccfinii,  etc.,  by  the  same  translator,  form  a 
volume  of  the  Sydenham  Society's  publications  issued  in  1854. 

Balthasar  Anthelme  Richerand  (1779-1840)  pul)lished  his  Nomgraphie 
rhlnn-gicale  (1805-06,  3  vols.;  5th  ed.  in  1821,  4  vols.).  He  was  ap- 
pointed ]irofessor  of  surgical  pathology  in  the  faculty  by  Xapoleon  in 
1807.  He  was  more  successful  as  a  writer  than  he  was  as  an  oi>erat(U- 
or  teacher,  but  he  had  nothing  of  the  impartial  spirit  of  the  true  critic, 
and  the  man  whom  he  praised  one  year  he  would  denounce  the  next. 
He  made  no  special  contributions  to  surgery  with  the  exception  of  a  case 
of  resection  of  the  fifth  and  sixth  ril)s  on  the  left  side,  being  the  first 
instance  in  which  such  an  ojieration  had  been  performeil  to  this  extent. 

Philibert  Joseph  Koux  (1780-1854)  was  a  student  and  warm  i)ersonal 
friend  of  Bichat,  \\hom  he  succeeded  as  a  teacher.  He  became  surgeon 
at  the  Charite  in  1810,  professor  of  surgery  in  the  faculty  in  1820,  and 
succeeded  Dupuytren  at  the  Hotel  Dieu  in  1835.     He  first  became  cele- 


THE  inSTOEV  AND  LITERATURE  OF  SURGERY.  107 

brated  by  the  publication,  in  1815,  of  his  Bekttion  d'nn  voyage  fait  a 
Londres  oi  I8I4.;  ou  parall^le  de  la  chinuyic  aiKjloinc  arcc  la  chirurc/ie 
franqoise — a  book  which  had  considerable  influence  in  dilfusing  in  each 
country  a  knowledge  of  what  had  been  done  in  the  other,  in  spite  of  the 
crude  and  superficial  views  on  many  points  which  it  presented.  His 
most  important  contributions  to  the  art  were  in  plastic  surgery,  partic- 
idarlv  in  staphylorrhaphy,  which  he  first  performed  in  181!l,  and  in 
suture  of  the  ruj)tured  perineimi,  which  he  first  performed  in  1832.  He 
gave  the  first  distinct  course  of  lectures  on  surgical  anatomy  in  1812. 
His  most  important  literary  work  was  his  Quarante  annecs  de  pratique 
chirurgicale,  of  which  but  two  volumes  were  published,  the  first,  relating 
to  plastic  surgery,  appearing  in  1854,  and  the  second,  on  diseases  of  the 
arteries,  in  1855. 

Jeau  Nicolas  Marjolin  (1780-1850)  was  prosector  of  anatomy  in 
1800,  and  in  1816  became  second  surgeon  of  the  Hotel  Dieu,  but  soon 
retired  to  avoid  unpleasant  association  with  Dupuytren.  In  1819  he 
became  professor  of  surgical  pathology.  He  was  a  good  surgeon  and 
extremely  popular  as  a  teacher,  but  was  not  distinguished  as  an  operator. 
His  name  remains  connected  with  the  form  of  malignant  degeneration  of 
chronic  ulcer  of  tlie  leg  known  as  the  "  Marty  ulcer  of  Marjolin." 

Jacques  Lisfranc  (1790-1847)  studied  at  Lyons  and  Paris  and  gradu- 
ated iu  1813,  after  which  he  served  for  a  short  time  in  the  army  and 
then  settled  in  Paris.  In  1825  he  became  second  surgeon  at  La  Pitie, 
and  a  short  time  afterward,  on  the  death  of  B^clard,  he  became  the 
chief  surgeon  at  this  hospital.  He  sought  to  reduce  ojicrative  surgery 
to  mathenuitical  rules,  and  his  name  is  connected  with  methods  of  par- 
tial amjjutation  of  the  foot,  of  amputation  at  the  wrist,  the  shoulder-joint, 
and  the  hi]),  and  with  methods  of  resection  of  the  head  of  the  humerus, 
for  removal  of  the  lower  jaw,  for  excision  of  the  rectum,  and  for  ampu- 
tation of  the  neck  of  tlie  uterus.  He  was  an  excellent  operator  and 
clinical  teacher,  liut  envious  of  the  greater  success  of  some  of  his  contem- 
poraries, particularly  Dupuytren  and  Velpeau,  and  died  dissatisfied  with 
himself  and  witii  every  one  around  him.  His  principal  publications  are — 
Clinique  chirurgicale  de  I'hopital  de  la  Fitie  (3  vols.  8vo,  Paris,  1841-43) 
and  Precis  de  raedecine  op^raioire  (3  vols.  8vo,  Paris,  1845—48). 

Louis  Joseph  Sanson  (1790-1841)  was  a  pupil  and  friend  of  Dupuy- 
tren. After  serving  in  the  army  from  1812  to  1.S15,  he  returned  to  Paris, 
and  in  1825  became  the  second  surgeon  of  the  Hotel  Dieu.  In  1836  he 
succeeded  Dupuytren  as  professor  of  clinical  surgery,  winning  the  place 
by  concours.  The  first  forty  years  of  his  life  were  a  continued  struggle 
with  ])overty,  and  his  subordination  to  Dujniytren  prevented  him  from 
obtaining  tlie  re|)utation  to  which  his  skill  as  a  diagnostician  and  operator 
entitled  him.  His  jjrincipal  work  was  the  Nourraux  elements  de  patho- 
logic medieo-chirurgicalc,  par  Roche  et  Sanson  (4  vols.,  1824  ;  3d  ed. 
1833),  of  which  he  wrote  all  the  surgical  part. 

Jules  Germain  Cloquet  (1790-1883)  came  to  Paris  in  1810  and  be- 
came preparer  for  the  museum  of  the  School  of  Medicine.  He  published 
a  valuable  scries  of  anatomical  observations  on  hernia  in  1817,  and  a 
magnificent  work  on  human  anatomy,  containing  a  large  number  of  plates, 
Mhich  is  still  classic;  in  1831  he  l)ecamc  ])rofessor  of  surgical  jiathoiogy, 
and  succeeded  Dubois  in  the  chair  of  clinical  surgery  iu  1833,  which 


lOS  THE  HISTOKY  AND  LITERATURE  OF  SURGERY. 

position  he  retained  until  ISTjO.  He  eontrihutcd  a  larjije  number  of 
papers  on  anatomical  and  surgical  subjects  to  the  journals,  and  devised 
a  number  of  new  instruments. 

Joseph  Souberbielle  (1754-1846)  studied  at  Paris  under  Desault  and 
entered  the  army.  He  took  his  degree  in  1813,  after  \v]ii<']i  he  remained 
in  Paris,  devoting  himself  chiefly  to  litiiotomy,  and  especially  to  the 
supraj)ubic  method.  He  was  a  relative  of  Frere  Come  and  of  his 
nephew  Baseilhac,  and  inherited  their  instruments  and  reputation.  He 
is  said  to  have  performed  the  suprapubic  operation  over  twelve  hundred 
times. 

To  this  period  l)elongs  the  introduction  of  lithotritv,  with  mIucIi  are 
especially  connected  the  names  of  Civiale,  Leroy  (d'lLtiollcs),  and  Hcur- 
teloup. 

Jean  Civiale  (1792-1867)  studied  at  Paris,  graduating  in  1820,  and 
made  a  specialty  of  the  diseases  of  the  urinary  organs,  and  especially  of 
lithotrity,  which  he  successfully  performed  on  a  living  human  subject  in 
January,  1824.  In  1828  a  special  section  for  those  afflicted  with  calculus 
was  set  apart  for  him  in  the  Hospital  Necker,  and  his  practice  became 
enormous.  He  had  much  mechanical  ingenuity  and  dexterity,  but  he 
was  neither  a  speaker  nor  a  writer,  and  the  greater  part  of  the  numerous 
publications  which  appeared  under  his  name  were  really  written  by 
Jourdan,  Boisseau,  Begin,  and  others.  In  his  first  book,  Xouirlles  con- 
siderations SUV  la  retention  (F urine,  etc.  (1823,  p.  115),  he  referred  to  a 
report  of  Pouteau  that  "  haricots  blancs  "  had  passed  from  the  stomach 
into  the  urinary  bladder,  etc.,  and  said  :  "  Si  les  faits  rapportes  sont  exacts, 
ccs  corps  suivent-ils  le  torrent  de  la  circulation?"  Some  kind  friend 
pointed  out  the  blunder  to  him  before  the  edition  was  put  on  the  market, 
and  he  cancelled  the  greater  part,  but  a  few  had  been  sent  out  as  pres- 
entation copies,  and  these  are  now  regarded  as  curiosities  in  medical 
literature. 

Jean  Jacques  Joseph  Leroy  (d'fitiolles)  (1798-1860)  studied  at  Paris, 
graduating  in  1824,  prior  to  which  he  had  devised  a  three-pronged 
instrument  for  seizing  and  perforating  a  stone  in  the  bladder,  and  his 
whole  life  was  mainly  devoted  to  this  branch  of  surgery  and  to  bitter 
contests  as  to  priority  of  invention.  He  was  not,  however,  a  pure 
specialist,  and  was  a  much  more  scientific  man  than  Civiale.  The  list 
of  his  publications  is  a  long  one,  but  they  are  comparatively  brief 
papers. 

Charles  Louis  Stanislaus  Heurteloup  (1793-1864),  son  of  Baron 
Nicolas  Heurteloup,  a  distinguished  French  army  surgeon,  studied  in 
Paris,  graduating  in  1823,  and  almost  inniiediatcly  turned  liis  attention 
to  the  suliject  of  lithotripsy  and  to  criticism  of  the  work  of  Civiale  and 
Leroy  (d'Etiolles).  He  greatly  improved  the  instruments  used  in  lith- 
otripsy, and  is  said  to  have  spent  one  hundred  and  fifty  thousand  francs 
in  perfecting  his  inventions.  From  1828  to  1832  he  was  in  London, 
and  published  there  hh  Principles  of  Lifliofriti/ {18SI). 

To  this  period  also  belong  Delpecli  and  Lallemand  of  INIontpellier. 

Jacques  Mathieu  Delpech  (1777-1832),  a  native  of  Toulouse,  gradu- 
ated at  :Montpellier  in  1801,  after  which  he  studied  in  Paris.  In  1812 
he  obtained,  by  concours,  the  chair  of  surgery  at  Montpellier,  and  soon 
became  celebrated  as  an  operator  and  as  a  clinical  teacher.    In  the  height 


THE  HISTORY  AND  LITERATURE  OF  SURGERY.  ]09 

of  liis  fame  he  was  assassinated  by  a  patient  wlioni  lie  liad  treated  for 
some  disease  of  tlie  genitals.  His  principal  contributions  to  snrgery 
relate  to  hospital  gangrene  and  to  ortiiopivdia.  He  tirst  j)i)inted  out  that 
tubercular  disease  of  the  vertebrte  was  the  frequent  origin  of  Pott's  dis- 
ease of  the  spine,  insisted  on  the  importance  of  the  tilirous  tissues  in  con- 
nection with  deformities,  and  in  181(3  performed  subcutaneous  section  of 
the  tcndo  Achillis  with  the  avowed  intention  of  thus  excluding  the  air 
and  obtaining  union  by  tirst  intention.  The  successor  of  IX'lpech  in 
the  chair  of  clinical  surgery  was  Michel  Serre  (1799-1849),  who  gradu- 
ated at  ^Nlontpellier  in  1825,  and  who  published  his  Trniie  de  la  reunion 
immediate,  etc.,  in  1830,  and  his  Traite  sur  Part  de  re.staurcr  les  difform- 
ifes  de  la  face,  etc.,  in  1842. 

Claude  Fraufois  Lallemand  (1790-1853),  a  native  of  Metz,  studied 
at  the  jNIilitary  Medical  School  of  that  j)lace,  and  at  the  age  of  thirteen 
entered  the  army  medical  service.  In  1811  he  went  to  Paris  and  became 
an  assistant  to  Dupuytren  ;  in  1819  he  was  appointed  professor  of  clinical 
surgery  at  Montpellier  ;  and  after  the  death  of  Delpech  he  was  the  chief 
surgeon  in  the  south  of  France.  In  1823  he  lost  his  jdace  for  ten  months 
through  clerical  intrigues,  but  M'as  repliiced  by  the  Council  of  Public 
Instruction.  He  is  best  known  as  the  author  of  T>ei<  jiertes  m'miiudes 
inrolontaires  (.3  vols.,  183*3-42),  of  which  several  English  translatiiins 
were  published.  He  devised  the  method  of  autoplasty  by  bending  with- 
out twisting  the  flap,  and  the  method  of  treating  erectile  tumors  by  the 
insertion  of  needles. 

In  the  third  period  (1835-47)  come  Gerdy,  Velpeau,  Blandin,  A. 
Berard,  I^augier,  Jobert,  Amussat,   and  Vidal. 

Pierre  Nicolas  Gerdy  (1797-185(3)  studied  in  Paris  under  the  most 
adverse  circumstances  of  poverty  and  sickness,  and  in  1828  became 
second  surgeon  to  La  Piti6,  where  he  was  under  the  orders  of  Lisfranc, 
who  gave  him  very  few  opportunities.  In  1831  the  surgeons  of  the 
hospitals  were  placed  on  an  ecpial  footing,  the  position  of  surgeon-in- 
chief  being  abolished.  In  1833,  as  the  result  of  an  intrigue  of  r)u])uv- 
tren  to  suppress  Velpeau,  Gerdy  became  professor  of  the  princij)k's  of 
surgery  in  the  faculty,  and  in  1839  was  appointed  surgeon  to  La  Charite, 
taking  the  place  of  Guerbois.  The  list  of  Gerdy's  works  is  a  long  one, 
but  he  was  a  physiologist  rather  than  a  surgeon,  and  his  most  important 
surgical  publication  was  his  Traite  de.^  bandages  et  de.H  ^Jonseinoit.t  (2 
vols.,  1837-39). 

Alfred  Armand  Louis  Marie  Velpeau  (1795-18(37),  the  son  of  a 
blacksmith,  whose  trade  he  learued,  studied  at  Tours,  ^\•here  he  received 
the  diploma  of  officier  de  sante,  and  in  1820  came  to  Paris,  and  soon 
became  assistant  preparer  for  Cloquet.  He  graduated  in  1823,  and  pub- 
lished his  Traite  d'anatomie  chirurgicule,  the  first  complete  and  syste- 
matic work  in  which  the  details  of  regional  anatoniv  were  throughout 
considered  with  reference  to  tlieir  surgical  relations.  In  1828  he  Ijecame 
surgeon  to  the  Hosj)ital  St.  Antoine,  and  in  1830  to  La  Pitie,  where  ho 
remained  until  1834,  when  he  was  elected  to  the  chair  of  clinical  sur- 
gery in  the  faculty  left  vacant  by  the  death  of  Boycr.  In  1832  he  ])ub- 
lished  his  Noiircaux  elements  de  medecine  oprndoire  (3  vols,  and  atlas), 
the  largest  and  most  complete  work  on  this  subject  which  liad  vet 
appeared.     The  English  translation  of  this  by  Townsend,  with   notes 


110  THE  HISTORY  AND  LITERATURE  OF  SURGERY. 

of  Valentine  Mott  (New  York,  1847),  and  especially  the  latest  edition, 
with  additions  by  G.  C.  Blackman  (New  York,  ISofi,  3  vols,  and  atlas), 
is  a  ^reat  storehouse  of  liistorical  data  relating-  to  the  prineipal  Oj)ei-a- 
tions  of  surgery  up  to  that  date.  In  18o4  he  pul)lishcd  his  Traitf  dcx 
maladies  du  .sehi,  a  large  hook,  eharai'terized  by  Trelat  as  the  most  orig- 
inal, personal,  and  probably  the  most  durable  of  his  works,  and  whicli 
must  not  be  confounded  with  his  Petit  traite  des  maladies  du  sein,  pub- 
lished in  1838  as  a  reprint  of  his  article  in  the  Dictionnaire  de  medecinr, 
and  which  was  translated  into  English  by  Parkman  in  1840.  He  made 
no  great  discoveries  or  improvements,  yet  he  contril)uted  grcatlv  to  the 
progress  of  surgery  Ix'tween  1825  and  1855,  and  especially  in  surgical 
anatomy,  the  pathology  of  pysemia,  the  diagnosis  of  tumors,  and  the 
diseases  of  the  breast.  A  man  of  strong  common  sense,  an  indefatigable 
M'orker,  a  conscientious  and  conservative  critic,  an  excellent  teacher  and 
operator,  his  lessons  were  followed  by  crowds  of  pupils,  including  mam- 
\\'h()  became  distinguished  surgeons  in  other  countries  as  well  as  in 
France. 

Philipp  Frederic  Blandin  (1798-1849)  graduated  at  Paris  in  1824, 
in  1828  became  a  surgeon  to  the  Hosj)ital  Bcaujon  under  Marjolin, 
and  in  1841  succeeded  Richerand  in  the  chair  of  ojierative  surgery. 
He  also  became  surgeon  to  the  Hotel  Dicu.  Blandin  was  not  a  great 
surgeon  nor  a  great  teacher,  and  there  is  little  in  his  writings  which  is 
of  interest  at  the  present  day,  but  he  was  a  sensible,  practical,  honest 
man  who  did  good  Avork  in   iiis  time. 

Augusta  Berard  (1802-46)  studied  at  Paris,  graduating  in  1829, 
became  a  surgeon  of  the  Central  Bureau  by  eoncours  in  1831,  and,  sul)- 
sequently,  surgeon  to  the  hosjiitals  St.  Antoine,  Salpetriere,  Nccker,  and 
La  Pitie,  and  in  1842  succeeded  Sanson  as  professor  of  clinical  surgery 
in  the  faculty.  The  student  part  of  his  life  was  one  of  great  poverty, 
shared  by  his  brother,  P.  Berard,  who  devoted  himself  to  physiology. 
A.  Berard  wrote  some  excellent  eoncours  theses,  many  articles  in  the 
Dictionnaire  de  medecine,  and  began,  with  Denonvilliers,  a  Compendium 
dc  chirur</ie  prati(jiic,  of  which  only  a  portion  was  issued  at  his  death. 
His  contributions  to  surgery  relate  to  the  treatment  of  fractures,  con- 
tinuous irrigation  of  wounds,  erectile  tuuKn's  and  varices,  staphylor- 
I'haphy,  etc.     He  was  a  skilful  operator  and  an  excellent  teacher. 

Stanislaus  Laugier  (1799-1872),  a  pupil  of  Dupuytren,  graduated  at 
Paris  in  1828,  became  surgeon  to  the  Hospital  Nccker  in  1832,  to  the 
Hospital  Beaujon  in  1836,  jirofcssor  of  clinical  surgery  in  the  faculty  in 
1848,  and  surgeon  to  the  Hotel  Dieu  in  1854,  succeeding  Roux.  He 
first  called  attention  to  the  discharge  of  serous  tluid  from  the  ear  in 
certain  fractures  of  the  skull,  and  was  the  first  to  propose  suture  of 
divided  nerves.  He  was  a  ]irudent,  quiet,  conservative  surgeon  and  a 
good  teacher,  but  he  wrote  little  and  his  name  is  now  almost  forgotten. 

Antoine  Joseph  Jobert  (1799-1867)  studied  at  Paris,  graduated  in 

1828,  was  appointed  a  surgeon  of  the  Central  Bureau   by  eoncours  in 

1829,  and  surgeon  to  the"  Hospital  St.  Louis  in  1831.'  In  1853  he 
became  surgeon  to  the  Hotel  Dieu,  and  in  1854  succeeded  Roux  as  pro- 
fessor in  the  faculty.  His  childhood  and  student-life  were  spent  in 
great  poverty,  at  times  in  actual  destitution  ;  his  subsequent  life  was  a 
very  unhappy  one,  in  S2jite  of  the  honors  and  wealth  to  which  he  attained  ; 


THE  HISTORY  AXD  LITERATURE  OF  SURGERY.  Ill 

he  became  gloomy  and  eccentric,  and  cndi'd  his  days  in  an  asyhini  for 
tlie  insane.  Lacking  in  preliminary  edncation  and  in  oratorical  gilts, 
liis  snccess  was  dne  to  the  novelty  and  importance  of  his  contrihutions 
to  plastic  surgery  and  to  the  surgery  oi'  the  female  organs  of  generation. 
He  was  a  better  writer  than  speaker,  and  wrote  much  ;  his  Mhnoire.  nur 
les  phucs  (hi  canal  intesfiiwl,  published  in  1826,  before  his  graduation, 
was  based  upon  the  experimental  method  of  Hunter,  and  demonstrated 
the  importance  of  producing  union  between  the  serous  surfaces.  His 
most  important  \vorks  were — Traitf  dc  chirurf/ie  plaatignc  (2  vols,  and 
atlas,  1849),  Traite  dcs  fishdes  vesico-iderines,  etc.  (1852),  and  I)c  la 
reunion  en  chirurgie  (1864). 

Jean  Zulema  Amussat  (1796-1856),  the  son  of  a  country  physician, 
entered  the  army  medical  service  in  1814,  after  which  he  studied  at 
Paris,  grachiating  in  1826.  He  did  not  become  a  professor  in  the 
faeultv  or  surgeon  to  a  great  hospital,  but  he  commenced  private  teach- 
ing even  before  he  graduated,  and  he  connuunicated  most  of  his  discov- 
eries to  the  Academy  of  Medicine,  which  granted  him  prizes  for  liis 
contributions  on  lithotrity,  on  the  torsion  of  arteries,  on  the  entrance  of 
air  into  the  veins,  on  lumbar  colotoniy,  etc.  He  wrote  much,  but  his 
papers  were  never  collected. 

Auguste  Theodor  Vidal  (de  Cassis)  (1803-56)  studied  at  Marseilles 
and  Paris,  graduating  in  1828,  soon  after  which  he  became  connected 
with  the  newly-founded  Gazette  des  hupitau.r.  He  never  became  a  pro- 
fessor or  connected  with  a  great  surgical  clinic,  and,  being  a  sarcastic 
journalist  and  rather  bitter  critic,  he  made  few  friends.  His  reputation 
as  a  surgeon  rests  upon  his  Traitr  de  patlinlor/ie  c.rtcrnc  (5  vols.,  18.">8 — 11 ), 
which  was  a  popular  manual  and  reached  a  fifth  edition  in  1860.  He 
invented  serres-tines,  was  the  first  to  inject  a  solution  of  nitrate  (if  silver 
into  the  uterine  cavity,  and  conti'ibuted  largely  to  our  knowledge  of 
syphilis,  successfully  opposing  Ricord,  the  great  authority  of  the  day,  in 
some  important  points  relating  to  this  disease. 

Joseph  (tcusouI  (1797-1858)  studied  at  Ijvous  and  Paris,  graduating 
in  1824,  and  in  1826  became  chief  surgeon  of  the  Hotel  Dieu  of  Lyons, 
where  he  soon  accjuired  celebrity  as  a  bold  and  skilful  operator.  He  first 
(in  1826)  excised  the  entire  upper  jaw,  in  1827  he  removed  the  parotid 
gland,  and,  first  in  France,  excised  half  of  the  lower  jaw,  and  he  first 
treated  varices  with  caustic.  He  M'rote  very  little,  his  chief  publication 
being  hia  Lcffre  chiriirf/icale  sitr  (pwltpies  iii(dadicii  r/ravcs  du  sinus  ma.v- 
illaire  et  de  I'os  ma.riUaire  inferieiir  (1833). 

Amedce  Bonnet  (1802-58)  studied  at  Paris,  where  he  graduated  in 
1832,  and  in  1833  obtained  the  position  of  surgeon  to  the  Hotel  Dieu 
at  Lj'ons  by  concours,  after  which  he  Ijccame  a  professor  in  the  school, 
and  was  soon  celebrated  as  a  teac-her.  His  principal  publications 
are — Traite  des  sections  tendine.uses  et  mnscidaircs  dans  la  strabisme,  la 
mjinpie,  etc.  (1841),  Traite  des  maladies  des  articidations  (2  vols.,  1845), 
and  Traite  de  therapentiqne  dcs  mrdadies  a rticidcdrcs  (1853),  which  latter 
remain  as  valualile  contributions  to  the  surgery  of  the  joints. 

Charles  Gabriel  Pravaz  (1791-1853)  studied  at  Paris,  graduated  in 
1824,  and  devoted  himself  to  ortho]);rdic  surgery,  associating  himself 
with  Jules  Guerin  in  a  private  orthupicdic  hospital.  In  1835  he  settled 
in  Lyons.     His  principal   contribiuions  to  surgery  relate  to  orthopiedia 


112  THE  HISTORY  AND  LITERATURE  OF  SURGERY. 

— which  he  was  one  of  the  first  to  ])lace  on  a  scientific  fonndation — to 
the  use  of  percliloride  of  iron,  to  tiie  use  of  fine  liollow  needles  for  the 
injection  of  varices  or  erectile  tumors,  etc. 

Raoul  Henri  Joseph  Scontettin  (1799-1871),  a  native  of  Lille, 
entei'ed  the  army,  and  i!;raduated  at  Paris  in  1822.  He  liecame  one  of 
the  most  distiniiiiisiied  of  Freneli  military  surgeons,  was  professor  in  the 
school  at  Metz  in  18;i(i,  and  in  184U  held  the  same  position  in  the  mili- 
tary hospital  at  Strasburg.  In  1854  he  was  in  charge  of  the  military 
liosjiital  in  Constantinople  and  Pera,  after  which  he  returned  to  Metz, 
and  was  in  charge  of  the  military  hospital  until  his  death.  He  was  a 
voluminous  writer  on  matters  connected  with  military  medicine  and 
surgery,  and  an  excellent  operator.  He  successfully  performed  traciie- 
otomy  on  liis  infant  daughter  six  weeks  old. 

Jean  Baptiste  Lucien  Baudens  (1804-57)  studied  in  Paris,  entered 
the  army  medical  service  in  1823,  and  graduated  in  1829.  He  served 
in  Africa  from  18.'50  to  1837,  in  1838  became  professor  in  the  hospital 
at  Lille,  and  in  1842  professor  at  Val  de  Grace.  He  M'as  a  distin- 
guished military  officer,  and  made  numerous  contriljutions  to  military 
surgery,  among  which  may  be  mentioned  his  ttuuque  des  pluies  d'armes 
fl  feu  (1836)  and  his  La  guerre  de  Crimee,  les  campements,  les  abris,  les 
mnbulances,  les  hopitaux,  etc.,  first  published  in  the  Revue  des  deux- 
moiides  in   1857,  and  in  separate  form  in   1858. 

Jean  Gaspard  ]?laise  Goyrand  {lS()3-6(j)  studied  at  Paris,  graduated 
in  1828,  and,  returning  to  his  native  city  Aix,  became  chief  surgeon  to 
the  hospital,  and  one  of  the  most  distinguished  of  the  French  provincial 
surgeons  of  his  day.  He  made  important  contributions  to  the  literature 
of  am])utations,  fractures  of  the  hnver  end  of  the  radius,  operations  for 
h)ose  l)odies  in  the  joints,  extirpation  of  the  tongue,  urethral  fistula, 
etc.  His  principal  work  is  his  ('Unique  cldruryicule  ;  viemoires  et  obser- 
vations de  ehirurgie,  etc:  (Paris,  1870),  published  after  his  death  by  Dr. 
Silbert. 

Jules  Roux  (1807-77),  a  native  of  Aix,  studied  at  Toulon,  entered 
the  naval  medical  service  in  1828,  and  became  professor  in  the  school 
of  Toulon  in  1842.  He  was  distinguished  as  an  operator  and  clinical 
teacher,  devised  a  useful  modification  for  disarticulation  of  the  foot, 
made  improvements  in  the  ojteration  of  trephining,  and  was  the  first  to 
make  use  of  iodine  injections  in  disease  of  the  shoulder-joint.  He  made 
numerous  contributions  to  the  journals  and  learned  societies,  but  jiwb- 
lished  no  important  separate  M'ork. 

To  the  fourth  period  (from  1847  to  the  present  time)  belong,  in  addi- 
tion to  those  already  referred  to  and  those  who  are  still  li\'ing  and  do 
not  yet  belong  to  history,  a  nundjer  of  well-known  surgeons,  of  whom 
the  most  prominent  at  Paris  were  Malgaigne,  Nelaton,  Denonvilliers, 
Chassaignac,  Richet,   Follin,  Broca,  Dolbeau,  Gosselin,  and  Tr^lat. 

Joseph  Fraufois  Malgaigne  (1806-65),  a  native  of  the  Vosges,  son  of 
an  officier  de  sante,  studied  at  l^u'is,  graduating  in  1831,  and  after  a  short 
term  of  military  service  in  Poland  settled  in  Paris,  where  he  became  a 
surgeon  of  the  Central  Bureau  in  1835,  and  began  to  teach  surgical 
anatomy.  He  was  successively  surgeon  to  the  Hospital  St.  Louis  and 
to  La  Charite,  and  in  1850  won  by  concours  the  chair  of  operative  sur- 
gery vacated  by  Blandin. 


THE  HISTORY  AND  LITERATURE  OF  SURGERY.  113 

Malgaigne  was  the  greatest  surgical  historian  and  critic  which  the 
worUl  has  yet  seen,  a  brilliant  speaker  and  writer,  whose  native  genins, 
joined  to  incessant  labor,  brought  about  a  new  mode  of  judging  of  the 
merits  of  surgical  procedures — the  mode  of  statistical  comj)arison  joined 
to  experiment.  He  was  not  a  great  operator,  and  although  he  made 
some  improvement  in  the  art,  such  as  his  hooks  for  the  treatment  of 
fractures  of  the  patella,  his  suggestion  of  suprathyroid  laryngotomy, 
etc.,  these  are  of  small  importance  as  compared  with  his  work  of  explod- 
ing errors,  exposing  fallacies  in  reasoning,  and  bringing  to  bear  upon 
tlie  work  of  the  present  day  the  light  of  tlie  experience  of  the  past,  of 
which  his  treatise  on  fractures  and  dislocations  affords  many  excellent 
examples.  The  reports  of  his  spci'clics  in  the  Bulletins  of  the  Academy 
of  ^Medicine  are  among  the  most  delightful  reading  in  surgical  literature. 

Auguste  Nelaton  (1807-73),  the  son  of  a  French  soldier,  a  native 
of  Paris,  studied  at  the  Hotel  Dieu  under  Du])uytren  and  at  the  Found- 
ling Hospital,  graduating  in  1836.  He  became  professor  of  clinical 
surgery  in  1851,  was  for  many  years  a  colleague  of  Malgaigne  at  the 
Hospital  St.  Louis,  and  for'  the  last  fifteen  years  of  his  life  was  the  most 
popular  surgeon  in  Paris.  He  was,  in  fact,  in  many  respects,  the  best  sur- 
geon whom  France  has  produced  during  the  century,  being  unsurpassed 
as  a  diagnostician,  as  an  ojierator,  and  as  a  clinical  teacher,  and  was  a 
modest,  quiet  gentleman  who  attacked  no  one  and  befriended  many.  He 
made  mnnv  improvements  in  surgical  tccluiiquc,  among  which  was  tlie 
porcelain-headed  prol^e  wliich  he  devised  for  demonstrating  the  presence 
of  the  bullet  in  Garibaldi's  ankle-joint.  He  brought  into  French  prac- 
tice the  principle,  so  strongly  insisted  on  by  Guthrie,  of  ligating  both 
ends  of  a  wounded  artery  within  the  ^v()und  for  either  primary  or 
secondarv  hemorrhage,  improved  tlie  methods  of  treatment  of  naso- 
jiharvngeal  tumors,  first  clearly  demonstrated  retro-uterine  hsematocele, 
and  brought  ovariotomy  into  good  repute  in  France.  He  wrote  com- 
paratively little,  his  chief  publication  being  his  Elements  cle  pafhologie 
chirurcjicale  (5  vols.,  1844—59,  of  which  the  last  two  volumes  were  pub- 
lished by  A.  Jamain).  The  only  publication  of  his  clinical  lectures  is 
that  made  in  1855  by  Dr.  ^y.  F.  Atlee  of  Phila<lelphia  from  his  own 
notes — a  book  which  is  not  nearly  as  well  known  as  it  deserves  to  be. 

Charles  Pierre  Denonvilliers  (1808-72)  studied  at  Paris  and  grad- 
uated in  1837;  became  a  surgeon  of  the  Central  Bureau  in  1840,  in 
1842  chief  of  the  School  of  Practical  Anatomy  and  surgeon  of  the 
Hotel  Dieu,  and  in  1856  professor  of  surgery.  He  was,  however,  more 
of  an  anatomist  than  a  surgeon,  although  he  was  a  good  operator, 
especially  in  tlie  field  of  plastic  surgery.  His  most  important  services 
to  medicine  were  rendered  in  his  cajiacity  as  inspector-general  of  public 
instruction  for  medicine,  to  which  he  was  appointed  in  1858. 

fidouard  Pierre  Marie  Chassaignac  (1804-79)  studied  at  Nantes  and 
Paris,  graduating  in  1835,  and  gave  private  courses  in  anatomy  and 
operative  surgery,  but  did  not  become  a  professor  in  the  fiiculty, 
altiiougli  he  often  competed  for  this  jiosition.  He  became  surgeon  to 
tlie  Laril)oisiere  in  1852.  His  most  important  contributions  to  surgery 
were  the  introduction  of  the  method  of  the  drainage  of  wounds  and 
abscesses,  his  method  of  di'cssing  wounds  by  complete  occlusion,  and  his 
invention  of  the  ecraseur. 

Vol.  I.— s 


114  THE  HISTORY  AND  LITERATURE  OF  SURGERY. 

Louis  Alfred  Richet  (1816-91),  a  native  of  Dijon,  studied  in  Paris, 
graduatinij  in  1844.  He  was  surgeon  to  tlie  liospitals  Loureine,  St. 
Antoine,  and  La  Pitie,  and  in  18()4  became  professor  of  elinieal  surgery 
in  the  faculty.  His  princij)al  work  was  his  TraiU'  prufiqac  d'anatomie 
medico-ehirurf/lnde  (Paris,  1857;  4th  ed.   187.')). 

Eugene  Follin  (182;}-67),  a  pupil  of  Veljieau,  was  a  skilled  anatom- 
ist and  excelled  in  diagnosis.  He  introduced  the  use  of  the  ophthal- 
moscope in  France.  His  early  death  left  his  Traite  rlniioitairc  dc 
pafliolni/ic  c.iiciiic  untinisiied,  but  it  was  continued  and  coni])letcd  in  six 
volumes  by  Duplay,  and  is  a  work  of  much  practical  value.  His 
contributions  to  surgery  are  characterized  by  freedom  from  exaggera- 
tion and  by  sound  sense. 

Paul  Broca  (1824-80),  the  son  of  an  army  surgeon,  studied  at  Paris, 
graduating  in  1849,  immediately  after  which  he  became  prosector  at  the 
Fcole  pratique.  In  185;5  he  became  assistant  profess(U'  in  the  fticulty, 
and  in  18(57  professor  of  surgery,  soon  after  which  he  exchanged  this 
chair  for  that  of  clinical  surgery.  He  was  successively  surgeon  to  the 
hospitals  St.  Antoine,  La  Pitie,  Des  Cliniques,  and  Necker.  He  was  an 
original  investigator  of  a  high  order,  as  is  shown  by  his  researches  on 
cerebral  localization,  aphasia,  etc.  Distinguished  as  an  anatomist,  a 
pathologist,  and  a  surgeon,  he  devoted  himself  in  the  latter  part  of  his 
life  more  especially  to  anthropology,  of  which  he  may  almost  be  said  to 
have  been  the  founder  in  France.  He  was  the  first  to  trephine  for  an 
abscess  of  the  brain,  the  location  of  which  was  determined  by  his  study 
in  the  localization  of  function  of  that  organ.  In  fact,  his  studies  may 
be  said  to  be  the  foundation  of  modern  brain-surgery. 

Henri  Ferdinand  Dol])eau  (1830-77)  studied  at  Paris,  graduating  in 
1856,  became  hospital  surgeon  in  1858,  serving  successively  at  the 
Hospital  for  Children,  Necker,  and  the  Hotel  Dieu,  where  he  replaced 
Jobert  in  1865,  and  in  1868  became  professor  in  the  faculty.  He 
contributed  to  our  knowledge  of  cluli-foot,  of  cartilaginous  tumors,  of 
epispadias,  and  of  spina  bifida,  suggested  lithotrity  through  perineal 
section  in  cases  of  large  calculus,  and  was  an  excellent  practical  teaclier. 
His  principal  works  are  De  V epispadias  (1861),  Tmite  pjndicjuc  dc  la  picrre 
dans  la  vessie  (1864),  and  Legons  de  dinique  chirurgic(dc  (1867). 

Athanase  Leon  Gosselin  (1815-87),  a  native  of  Paris,  graduated  in 
1843,  and  became  surgeon  to  the  hospitals,  and  in  1858  professor  of 
surgery  in  the  faculty,  and  surgeon  to  La  Charitc  in  18()7.  He  contrib- 
uted to  journals  many  \'aluable  papers  which  were  collected  and  pub- 
lished in  his  Clinique  chirurgicalc  de  r/topitid  de  la  Charite  (2  vols., 
1873;  3d.  ed.  1879,  and  translated  into  English,  Philadelphia,  1878). 

Ulysse  Trelat  (1828-90),  the  son  of  a  physician,  and  a  native  of  Pari.s, 
studied  at  Paris,  graduating  in  1854.  He  became  jjrosector  in  1856,  in 
1857  assistant  ])rofi'ssor  in  surgery  to  the  faculty,  and  in  1S6()  surgeon 
of  the  Central  Bureau,  serving  successively  at  tlic  liospitals  Maternite,  St. 
Antoine,  St.  Louis,  La  Pitie,  and  La  Charite.  He  l)ecanie  professor  of 
surgical  pathology  in  the  faculty  in  1872.  He  was  an  eloquent  speaker 
and  fond  of  speaking,  a  very  popular  clinical  teacher,  and  the  first  in 
France  to  recognize  the  importance  of  the  new  antiseptic  method. 
His  publications  were  mainly  in  journals  and  transactions ;  they  relate 
chiefly  to  plastic  surgery  of  the  j)alate  and  of  the  face,  to  hernia,  tuber- 


THE  HISTORY  AXD  LITERATURE  OF  SURGERY.  115 

ciilosis  of  the  tong'ue,  a^s(i|)]i;iuiiti)my,  etc.  His  Lcgons  de  cliniqiie 
chu-urgicale  appeared  in  1877,  ami  his  LTtnique  chirun/icnlc  (2  vols.)  in 
1891. 

In  addition  to  these  mav  be  mentioned  the  i'olh)win<r  : 

Joseph  Pierre  Eleonor  Petrequin  (1809-76)  studied  at  Paris,  gradu- 
ating in  1835,  in  1838  became  an  assistant  surgeon  in  the  Hotel  Dieu  at 
Lyons,  and  in  1855  became  professor  of  surgery  in  the  school.  He  was 
a  learned  historian  in  matters  pertaining  to  the  art,  a  skilled  physician 
as  well  as  surgeon,  and  a  voluminous  writer.  His  principal  publicaticms 
are — Traife  (Vanatomie  iiu'dico-c-hirurgk-ak  ct  topo<jfaphujue  (1844  ;  2d 
cd.  1857,  translated  into  German,  1845),  CTinique  chirnrglcale  dc  I' Hotel 
Dieu  de  Lyon  (1850),  Melanges  de  chirurgie  et  de  medecine  (1870,  1873, 
1877),  and  Chirurgie  d'Hipp'oerate  (2  vols.,  1878). 

Joachim  Albin  Cardozo  Cazado  Giraldes  (1807-75),  a  native  of 
Portugal,  studied  at  Paris  and  graduated  in  183().  In  1848  he  liecame 
a  surgeon  of  the  Central  Bureau,  and  was  appointed  to  the  Children's 
Hospital.  The  results  of  his  work  in  this  hospital  ap}X'ar  in  his  Legons 
cliniques  su)-  les  maladies  chirnrgieides  des  enfants,  etc.  (18(J9). 

Charles  Emmanuel  Sedill(it  (1804-83),'  a  native  of  Paris,  studied 
under  Rover  and  Roux,  and  in  1824  at  the  Val  de  Grace.  He  gradu- 
ated in  1829,  after  wiiich  he  entered  the  military  service,  and  in  183(3 
became  professor  of  operative  surgery  at  Val  de  Grace.  In  1841  he 
became  professor  of  surgery  at  Strasburg  by  concours,  succeeding  Begin. 
He  made  many  valuable  contributions  to  surgery,  relating,  among  other 
things,  to  dislocations,  plastic  operations,  urethrotomy,  pyiemia,  the  sur- 
gery of  the  bones,  gastrotomv — to  wliich  he  gave  the  name — operations 
for  cancer  of  the  tongue,  etc.  In  1840  he  performed  the  first  successful 
amputation  at  tiie  hip-joint  in  Paris. 

Paul  Louis  Benoit  Guersaut  (1800-70),  son  of  a  celebrated  Paris 
physician,  studied  at  Paris,  graduated  in  1828,  and  in  1833  became 
surgeon  to  the  Children's  Hospital  by  concours,  remaining  in  this  posi- 
tion until  18(30.  His  principal  work  is  his  ^Vo^/ccs  sur  la  chirurgie  des 
enfanh  (18(34-(37;  translated  into  English,   1873). 

Jules  Rene  Guerin  (1801-8(3),  a  native  of  Boussu  (at  present  in  Bel- 
gium), studied  at  Paris,  being  a  jiupil  of  B(iver  and  Roux,  and  graduated 
in  1826.  In  1830  he  founded  the  Gazette  viedicale  de  Paris,  of  wiiich 
he  was  the  editor  for  forty  years.  He  devoted  Iiimself  to  orthopjedic 
surgery,  having  established  a  private  orthopaedic  hospital,  and  in  1838 
publisiied  his  first  memoir  on  deformities  of  the  osseous  system,  which 
was  followed  by  a  long  series  of  similar  jiapers.  A  portion  of  these 
have  been  collected  and  jiublished  under  the  title  (Euvres  du  docteur 
Jules  Guerin,  etc.  (Paris,  1882),  said  to  have  been  intended  to  fill  16 
volumes,  with  100  j)lates,  but  which  has  never  been  finished.  As  a 
controversialist  and  •journalist  he  was  better  known  and  better  liked 
among  non-jirofessional  persons  than  among  those  of  his  own  pro- 
fession. 

Felix  Adolplie  Richard  (1822-72)  studied  at  Paris,  and  graduated 
in  1848.  He  became  surgeon  of  the  Central  Bureau  in  1852,  and  as- 
sisted Nelaton  in  his  clinical  teaching.  His  princijial  work  is  his  Pratique 
journaliere  de  la  chirurgie  (1868). 

^\'Iien  the  Austrian  Netlicrlaiids  became  a  part  of  the  French  Re- 


lU)  THE  HISTORY  AND  LITERATURE  OF  SURGERY. 

public,  in  1795,  the  five  modical  scIkioIs  in  Bclj^iiini  were  snpjirci^secl,  as 
those  in  France  had  been,  and  with  much  tlie  same  results.  Each  lai-ge 
town  attempted  to  regulate  the  matter  by  local  examinations  and  by  the 
establishment  of  schools  of  an  inferior  class,  mainly  devoted  to  giving 
instruction  in  surgery  and  obstetrics  to  uneducated  men.  \\'hcn  the 
kingdom  of  the  Netherlands  was  created  in  1815  the  Universities  of 
Ghent  and  Liege  were  established  and  the  iild  University  of  Louvain 
was  rehabilitated.  In  organizing  these  schools  a  strong  German  element 
was  introduced,  and  it  was  ordered  that  the  lectui'es  should  be  given  in 
Latin.  The  result  was  a  failure,  for  Paris  was  the  great  medical  school 
of  the  day,  and  the  Belgian  students  went  there.  The  Revolution  of 
1830  closed  the  universities,  and  in  1835  medical  teaching  was  placed 
substantially  on  the  French  basis. 

The  leading  surgeons  of  Holland  in  this  century  have  been  Hen- 
driksz,  Onsenoort,  Tilanus,  and  Ranke. 

Pieter  Hendriksz  (1779-1845)  served  in  the  army,  studied  at  Gron- 
ingen,  where  he  began  to  teach  surgery  in  the  hospital  in  1810,  in  1827 
was  called  to  Leyden,  and  in  1828  to  Amsterdam  as  professor,  which 
position  he  resigned  in  1832.  He  published  descriptions  of  his  opera- 
tions in  the  Groningen  hospital  in  1816,  in  1822,  and  in  1828. 

Anthony  Gerard  van  Onsenoort  (1782-1841),  a  surgeon's  apprentice, 
served  in  the  army,  began  to  teach  in  Lowen  in  1817,  and  in  1822  con- 
tinued teaching  in  Utrecht.  He  publislied  De  mUitaire  chimrr/ic  (1832) 
and  iJc  operative  heclkunde  (3  vols.,  1835-37),  besides  several  works  on 
ophthalmology. 

Christian  Bernard  Tilanus  (1796-1883),  a  native  of  Harderwijk, 
studied  at  Utrecht,  graduating  in  1819,  and  then  in  Paris  under  Dupuy- 
tren  and  Lisfranc,  and  in  1828  became  professor  of  surgery  and  obstet- 
rics in  the  school  at  Amsterdam,  where  he  was  the  first  to  give  regular 
clinical  teaching  in  surgery  in  the  hospital.  He  ceased  teaching  in 
1872. 

Hans  Rudolph  Ranke  (1849-87),  a  native  of  Kaiserwerth  and  a 
pupil  of  Volkmann,  graduated  at  Halle  in  1874,  and  in  1876  became 
professor  of  surgery  at  Groningen.  He  contributed  a  number  of  papers 
to  journals,  but  published  no  important  work. 

At  the  beginning  of  the  nineteenth  century  the  leading  Italian  sur- 
geons were  Scarpa,  Palletta,  Monteggia,  and  Vacca  Berlinghieri. 

Antonius  Scarpa  (1752-1832)  studied  at  Padua  under  Morgagni, 
graduating  in  1770  at  the  age  of  eighteen.  Two  years  later  he  was 
ajipointed  professor  of  anatomy  and  theoretical  surgery  at  the  University 
of  Modena,  and  in  1783  was  appointed  by  Joseph  II.,  emperor  of 
Austria,  as  professor  of  anatomy  at  the  University  of  Pavia,  to  which 
was  added  in  1787  the  chair  of  clinical  surgery.  He  retained  l^oth  these 
professorships  until  1803,  when  he  gave  up  anatomical  teaching,  Init  con- 
tinued to  teach  in  clinical  surgery  until  1812.  He  was  the  most  cele- 
brated Italian  anatomist  and  surgeon  of  his  day,  and  his  talent  as  an 
artist  enal)led  him  to  illustrate  his  discoveries  in  a  manner  which  at  once 
attracted  general  attention.  His  name  is  perpetuated  in  surgery  by 
"  Scarpa's  triangle." 

Giovanni  Battista  Palletta  (1747-1832)  graduated  at  Padua  in  1769, 
and  in  1787  became  chief  surgeon  of  the  Hospital  Maggiore  in  Milan, 


THE  HISTORY  AND  LITERATURE  OF  SURGERY.  117 

ami  gave  lessons  in  anatomy  and  clinical  snrgery.  He  M'as  greatly 
beloved,  and  his  death  was  consitlered  as  a  public  calamity  in  Milan. 

Giovanni  Battista  Monteggia  (1762-1815)  became  professor  of  anat- 
omy and  surgery  in  Milan  in  1795,  and  was  associated  with  Scarpa  in 
the  preparation  of  Istituzioiii  di  chii-un/ut,  (5  vols.,  1802-03;  4tii  ed., 
7  vols.,  1829-30). 

Andrea  Yacca  Bei-linghieri  (1772-1826),  son  of  Francesco  ^'acca 
Berlinghieri,  professor  of  medicine  at  Pisa,  studied  at  Paris  under 
Desault  and  at  London  under  John  Hunter,  and,  returning  to  Pisa, 
graduated  in  1791.  In  1801  he  became  professor  of  surgery  at  Pisa, 
and  soon  acquired  a  great  reputation. 

In  the  middle  of  the  century  the  best-known  Italian  surgeons  were — 
Luigi  Porta  (1800-75),  who  studied  at  Pavia,  was  for  three  years  in 
Vienna,  and  became  professor  of  clinical  surgery  at  Pavia  in  1832, 
which  ])ositi(>n  he  held  until  his  death  ;  and  Francesco  Rizzoli  (1809-80), 
professor  of  surgery  and  obstetrics  in  Bologna  in  1840,  who  was  distin- 
guished as  an  operator  and  teacher. 

The  scheme  of  medical  studies  adopted  in  Austria  in  1810  prescribed 
a  five  years'  course  in  medicine  or  the  higher  surgery,  and  a  two  years' 
course  tVn-  country  doctors.  In  1822  tiie  course  at  the  Military  Medieo- 
chirurgical  Academy,  or  Josephinum,  was  extended  to  five  years,  and 
this  college  had  the  right  to  grant  degrees.  In  1849  much  more  power 
was  given  to  the  professors  in  the  various  universities  as  to  the  arrange- 
ment of  studies,  but  a  complete  separation  between  the  faculties  and  the 
medical  associations  was  not  made  until  1873.  In  1872  separate  diplo- 
mas for  surgery  were  abolished. 

In  Prussia  a  system  of  medical  study  was  arranged  in  1825.  It  pro- 
vided for  physicians  who  studied  at  the  universities,  and  for  what  were 
called  surgeons  of  the  first  and  second  class.  The  surgeons  of  the 
second  class  were  surgeons'  apprentices  who  served  for  a  short  time 
in  a  military  hospital  or  attended  a  few  lectures  at  a  medico-chirurgical 
college  ;  their  examination  was  a  very  easy  one,  but  demanded  some 
knowledge  of  anatomy,  and  they  were  mostly  comparatively  uneducated 
men  of  an  inferior  class.  The  surgeons  of  the  first  class  had  to  study 
at  a  university  or  a  medico-chirurgical  school  for  three  years,  and  were 
not  required  to  know  Latin,  as  were  the  physicians,  showing  that  sur- 
gery was  still  considered  inferior  to  medicine.  In  1852  it  ^^•as  ordered 
that  there  should  be  but  one  class  of  doctors,  but  the  obtaining  a  med- 
ical degree  did  not  give  the  right  to  ]tractise.  At  present  the  education 
and  the  standing  of  physicians  and  of  surgeons  are  the  same  throughout 
the  empire. 

During  the  first  fourteen  years  of  the  nineteenth  century  the  Xapo- 
leonic  wars  produced  an  urgent  demand  for  army  surgeons,  esjiecially  in 
Austria,  which  was  often  the  field  of  conflict.  Vienna  had  the  leading 
surgical  schools  in  Germany  at  that  time,  founded  by  Leber  in  connec- 
tion with  the  university,  and  In-  Braml)illa  in  connection  with  the  Mili- 
tary Medical  School,  and  the  princijial  surgeons  in  Southern  Germany 
after  Leber  were  von  Kern,  Rudtorffer,  ^^'attmann,  and  Zang. 

Vincenz  Sebastian  von  Kern  (1760-1829),  professor  of  surgery  at 
Laibach  in  1797,  became  professor  of  practical  and  clinical  surgery  in 
the  Vienna  University  in  1805,  and  exercised  a  powerful  influence  on 


118  THE  HISTORY  AND   LITERATURE  OF  SURGERY. 

tile  (lovclopnicnt  of  siirjierv  iiiiil  suru'ical  teachini;  in  (u'niiany  and 
Xorthurn  Italy  nntil  his  resif^nation  in  1824.  He  groatly  .simplified 
the  prevailing  treatment  of  wounds,  returning  to  the  water-dressings 
of  Magatus  and  I'ejecting  plasters  and  salves,  and  was  a  skilful  operator 
and  an  exeellent  teacher. 

Franz  Xav.  Riidtorffcr  (1  TfiO-ls;].'))  commenced  teaching  in  tlic  great 
Vienna  Hospital  in  ISO],  .nid  in  ISIO  succeeded  Ijel)cr  as  ])rofessi)r  of 
surgery,  which  position  lie  lield  until  he  retired  in  18121. 

Joseph  von  Wattniann  (177!)-18(j(i),  son  of  a  surgeon  and  })upil  of 
von  Kern,  became  ])rofessor  at  Laibach  in  1816,  at  Innsbruck  in  1818, 
and  at  Vienna  in  1S24,  retiring  in  1848.  He  was  a  celebrated  operator, 
and  gained  great  re])utation  as  a  teacher. 

Cliristoph  B.  Zang  (1 772-1 S."]"))  graduated  at  Vienna,  entered  the 
Austrian  army,  and  in  18U6  became  professor  of  surgery  in  the  Josephi- 
num.  He  published  Darstclhtng  hlutiger  hcilkunstleri.^eher  Operationen 
(4to,  181.3-21) — an  excellent  manual  of  operative  surgery,  which  reached 
a  third  edition  and  was  translated  into  Italian. 

In  North  Germany  the  principal  surgeons  of  this  period  were 
Mnrsinna,  Rust,  C.  J.  M.  Langenl)eck,  v.  Walther,  Hesselbach,  and 
Briinninghausen. 

Christian  Ludwig  Mursinna  (1744-1823),  a  barbei-'s  apprentice,  en- 
tered the  Prussian  army  in  1701  under  Theden.  In  1787  he  became  sur- 
geon-genei'al,  and  professor  of  surgery  in  the  military  medical  school 
at  Berlin,  which  jiosition,  in  connection  with  that  of  surgeon  to  the 
C'harite,  he  retained  after  his  retirement  from  military  service  in  1809. 
He  was  a  skilful  operator  and  a  good  administratoi",  who  greatly  im- 
proved the  medical  service  in  the  Prussian  army,  but  wrote  little 
except  occasional  addresses  and  papers  for  journals. 

Joh.  Xeponudv  Rust  (1775-1840)  studied  in  Vienna  and  Prague,  and 
became  professor  of  surgery  at  Cracow  in  1803.  From  1810  to  18ir) 
he  was  one  of  the  surgeons  of  the  General  Hospital  in  A'ienna,  and  in 
1816  he  succeeded  Mursinna  in  the  army  medical  school  at  Berlin, 
becoming  professor  in  the  University  of  Berlin  in   1824. 

Conrad  Joh.  M.  Langenbeck  (1776-1851)  studied  at  Jena,  Vienna, 
and  Wiirzburg,  and  in  1802  settled  in  Gottingen,  where  he  soon  began 
to  teach  anatomy  and  surgery.  In  1.S14  he  became  professor  of  anatomy 
and  surgery  and  surgeon-general  of  tiie  Hanoverian  army.  In  1802  he 
published  a  treatise  on  litliotomy  ;  in  1806  the  first  volume  of  his  Biblio- 
thck  fiir  die  Chii-urgie,  of  which  the  eighth  and  last  volume  appeared 
in  1828  ;  and  in  1822  the  first  volume  of  his  Nono/or/ic  ini<J  Thcmpie. 
der  chiriirgiftchc7i  Kranhhciten,  etc.,  of  which  vol.  v.  appeared  in  IS.'iO. 
He  was  a  skilful  anatomist  and  o])erator,  modifying  and  improving  tiie 
technique,  and  a  celebrated  teacher. 

Philip  Franz  v.  Walther  (1782-1849)  was  educated  at  Heidelberg  and 
Vienna,  and  became  profes.sor  and  surgeon  to  the  hospital  at  Bamberg 
M-hen  he  was  only  twenty-one  ^-ears  old.  In  1804  he  became  professor 
of  physiology  and  surgery  at  Laudshut,  and  soon  acquired  a  high  rc])u- 
tation  as  an  operator  and  teacher.  In  1818  he  accepted  a  call  to  the 
newly-organized  university  at  Bonn,  where  he  soon  became  the  leading 
German  surgeon  of  his  time.  In  18.30  he  went  to  Munich  as  ]irofessor 
of  surgery  in  the  university,  which  had  been  transferred  to  tiiat  city 


THE  HISTORY  AXD  LITERATURE  OF  SURGERY.  119 

from  Landshut,  and  as  director  of  the  surijieal  clinic  in  the  General 
Hospital,  in  which  positions  he  remained  until  his  death.  He  was  the 
fountler  of  modern  surgery  in  Bavaria,  and  his  physiological  training- 
was  of  great  assistiince  in  his  surgical  teaching.  He  wi'ote  a  Si/fitcm  dcr 
Chi  I'll  rr/ir  (18;i3)  and  numerous  papers  for  periodicals. 

Franz  Caspar  Hesselhaeh  (17.")y-181())  was  a  pupil  of  Von  Sicl)old  at 
Wiirzliurg,  and  his  assistant  in  anatomical  demonstrations.  His  principal 
ei)ntril)utions  to  surgery  are  his  papers  on  hernia,  jniiilished  in  ISOti, 
1814,  and  1815,  in  the  tirst  of  which  he  gives  the  first  distinct  descrip- 
tion of  the  two  forms  of  inguinal  hernia. 

Hermann  Joseph  Briinninghausen  (1761-1834)  was  professor  of  sur- 
gery at  Wiirzliurg  in  the  early  part  of  the  century,  and  i)ul)lishcd  his 
J^rf(iJiruiH/cn    und  B<'iiicrki(iif/cn    liber  die  Aiajjuteftion   in   1818. 

Between  18-2o  and  IS.jO  the  leading  (Jerman  surgeons  were  Graefe, 
Dietfenbach,  and  Clielius,  in  addition  to  the  survivors  of  those  already 
referred  to. 

Carl  Ferdinand  von  Graefe  (1787-1840)  studied  at  Dresden,  Halle, 
and  Leipzig,  in  1810  became  professor  and  directcu- of  tiie  surgical  clinic 
in  the  newly-founded  University  of  Berlin,  and  from  181.3  to  181.5 
served  as  siu'geou-general  of  division  in  the  army.  In  181(3  he  tirst 
performed  suture  for  congenital  cleft  [lalate,  and  then  devised  blejiharo- 
plasty  and  rhinoplasty,  which  he  introduced  to  notice.  He  was  one  of 
the  tir.st  to  re-sect  a  portion  of  the  lower  jaw,  and  the  first  in  Germany 
to  ligate  the  innominate  artery. 

Johaun  Frictlrich  Diett'enljach  (1792-1847)  was  a  native  of  Konigs- 
berg,  where  he  studied  fmni  1818  to  1820,  when  he  went  to  ]5oiui  and 
became  the  j)upil  of  von  ^\'alther.  In  1821  he  went  to  Paris  and  Mont- 
pellier,  attending  the  clinics  of  Dupuytren  and  Delpech,  and  in  1822 
graduated  at  Wiirzburg,  his  thesis,  Xonnulla  de  ref/eneraiione  et  trana- 
plctnUdinne,  indicating  the  trend  of  his  studies.  In  1823  he  went  to 
Berlin  and  devoted  himself  largely  to  plastic  surgery.  In  1829  he 
became  surgeon  to  the  Charite,  and  in  1832  professor  extraordinary  in 
the  university,  at  which  time  he  began  his  work  in  orthopjedic  surgery. 
In  1829  he  devised  the  section  of  the  tendons  of  the  ocular  muscles  for 
strabismus,  which  made  a  great  sensation  in  the  surgical  world.  In 
1840,  after  the  death  of  von  Graefe,  he  became  professor  in  the  uni- 
versity and  director  of  the  surgical  clinic.  He  made  many  valuable 
(■ontriiiutions  to  methods  in  plastic  surgery  and  tenotomy,  which  are 
summed  up  in  his  (Jpercdive  C'hirurgie  (2  vols.,  1845-48).  His  enthusi- 
asm for  novelties  led  him  into  some  blunders,  as  in  his  publications  on 
the  cure  of  stammering  by  subcutaneous  section  of  the  muscles  of  the 
tongue,  but  he  was  a  great  sin-geon,  a  most  skilful  operator,  and  an 
extremely  poj)ular  clinical  teacher. 

Max.  Jos.  von  f'helius  (1 794-1 87<j),  a  native  of  Mannheim,  gradu- 
ated at  Heidelberg  in  1812,  ..fter  which  he  studied  under  A\'alther  at 
Landshut  and  Vienna,  and  became  professor  at  Heidelberg  in  1819. 
Here  he  soon  founded  a  surgical  and  ophthalmological  clinic,  and  in 
1822—23  published  his  Handbuch  der  Cliimrr/ie,  which  for  the  next 
twenty-five  years  was  the  best-known  manual  in  Crcrmany,  and  indeed 
in  Furope,  having  been  translated  into  Fnglish,  French,  Italian,  Danish, 
an<l  Dutch,  and  the  eighth  German  edition  having  been  issued  in  1857. 


120  THE  HISTORY  AND  LITERATURE  OF  SURGERY. 

The  English  transhition  by  Soiitli  (in  1847)  is  especially  valuable,  being 
nearly  doubled  in  size  by  the  notes  of  the  translator,  and  permitting  of 
a  dii'ect  comparison  of  the  English  and  German  surgery  of  that  day. 
He  was  one  of  the  best-known  surgeons  in  Europe  and  had  many  dis- 
tinguished pupils. 

To  this  period  also  belong  von  Textor,  Jaeger,  Blasius,  Wutzer,  von 
Anunon,  Wernher,  Kuhl,  Grossheim,  Fricke,  Mojsisovics,  Holscher, 
and  Jk'uedict. 

Kajetan  von  Textor  (1782-1860)  studied  at  Landshut  under  von 
Walther  and  graduated  in  1 808,  after  which  he  spent  two  years  in  Paris 
mainly  following  the  teaching  of  Boyer,  and  a  season  at  Pavia  under 
Scarpa.  In  1816  he  became  professor  of  surgery  at  M'iirzburg,  and 
held  this  position  until  1853  with  the  exception  of  the  years  18;32-;33. 
He  puljlished  Gnmdzuge  zur  Lehre  dcr  chinirgm'hcn  Operafionen,  etc., 
in  1835,  and  some  small  monographs.  His  chief  surgical  contributions 
related  to  resections,  in  which  he  was  a  very  skilful  operator.  His  son 
Carl  (1815-80)  became  assistant  professor  of  surgery  at  ^^'iirzl)iu-g  in 
1850,  and  contributed  a  number  of  surgical  ])apers  to  periodicals. 

Michael  Jaeger  (1795-1838)  graduated  at  AA'iirzburg  in  LSI 9,  and  in 
1826  succeeded  Schreger  as  director  of  the  surgical  clinic  at  Erlangen, 
becoming  professor  of  surgery  in  1831.  In  1832-33  he  was  professor 
of  surgery  at  Wiirzburg  during  von  Textor's  absence,  after  which  he 
returned  to  his  old  position  at  Erlangen.  He  contributed  materially  to 
the  literature  of  resections  and  of  diseases  of  the  l:)ones  and  joints. 

Ernst  Blasius  (1802-75),  a  native  of  Berlin,  studied  at  the  Friedrich 
Wilhelm  Institut  and  graduated  in  1823,  after  which  he  served  four 
years  in  the  array,  and  then  settled  in  Halle,  where  he  became  professor 
of  surgery  in  1834.  His  principal  work  was  his  Handbuch  der  Al-hm/ie 
(3  vols,  and  atlas,  1830-33),  but  he  also  published  collections  of  cases 
and  essays,  a  treatise  on  amputations,  and  numerous  papers  in  the 
journals. 

Carl  Wilhelm  Wutzer  (1789-1863),  a  native  of  Berlin,  studied  at 
the  Pepiniere,  served  in  the  army,  and  became  director  of  the  surgical 
school  at  Miinster  in  1821.  In  1830  he  succeeded  Weiuhold  as  pro- 
fessor of  surgery  at  Halle,  and  in  1833  took  the  same  chair  at  Bonn. 
He  ctmtributed  numerous  articles  to  periodicals,  but  wrote  no  important 
works,  and  is  best  known  as  the  originator  of  the  method  for  the  radical 
cure  of  inguinal  hernia  which  bears  his  name.  He  was  a  skilled  anat- 
omist, a  good  operator,  and  a  painstaking,  careful  teacher. 

Friedrich  August  von  Ammon  (1799-1861)  studied  in  Leipzig  and 
Gottingon,  graduating  in  1821,  and  settled  in  Hresdeu,  wlicre  he  became 
professor  in  the  surgical  school  in  1828,  resigning  in  1837.  The  greater 
part  of  his  numerous  publications  relate  to  ojjhtlialniology,  but  he  also 
devoted  much  attention  to  plastic  surgery  and  to  orthopsedia.  In  con- 
nection with  Baumgarten  he  published  Die  plastische  Chinirgie  nach 
ihren  Leistungen  kritisch  dargestellt  (1842),  and  in  the  same  year  appeared 
his  Die  angeboycnen  Krankhcitcn  r/c.s  Mrnxehcn,  etc.  (in  folio  with  plates), 
which  is  a  classic.  Another  finely-illustrated  work  is  his  Klini.sche 
DarsteUung  dcr  Kranhheitcn  und  JJildiiiK/sfclder  dcs  mcnscJdichcn  Aiigc.'^, 
etc.  (fob,  1838-41). 

Adolph  Wernher   (1809-83)    graduated  in   1832  at  Giessen,  where 


THE  HISTORY  ASD  LITERATURE  OF  SURGERY.  121 

he  became  jirofcssor  of  surgery  and  directt)r  of  tlie  surgical  clinic  in 
1837,  retiring  in  1878.  His  Handbueh  dcr  allgemeinen  und  spccidleii 
Ghirurgie  (4  vols.,  184(j-47)  was  an  excellent  manual,  of  which  the  first 
volume  of  a  second  edition  appeared  in  18(j2-63. 

Karl  August  Ivuhl  (1774-1840)  studied  at  Leipzig,  graduating  in 
1803,  after  which  he  went  to  Vienna,  London,  and  Paris.  In  1817  he 
became  assistant  professor,  and  in  1824  professor,  of  surgery  at  Leipzig. 
He  was  a  bold  and  skilful  operator,  and  ligated  the  innominate,  the 
subclavian,  and  both  carotids,  all  of  which  cases  he  described,  but  he 
wrote  no  important  work  and  made  no  special  contributions  to  surgical 
progress. 

Ernst  Leopold  Grossheim  (1799-1844),  a  pupil  of  the  Friedrich 
Wilhelm  Institut  in  Berlin,  was  an  army  surgeon  and  a  teacher  in  the 
surgical  school  at  Miinster,  who  publisiicd  a  Lehrbuch  der  o^icrativen 
Cliirurcjie  (3  vols.,   1830-35). 

Joh.  Carl  George  Fricke  (1790-1841)  studied  at  Giittingen,  where  he 
graduated  in  1810,  after  which  he  studied  in  Berlin  under  von  Graefe. 
In  1814  he  settled  in  Hamburg  and  became  surgeon  of  the  General 
Hospital.  He  jjublished  the  records  of  his  clinical  work  in  the  Amuden 
der  clururgisclwn  AhtJicihing  des  cdlf/.  Krankenhaunci  in  Hninhiirg  (2 
vols.,  1828-33),  and  in  various  journals,  especially  in  the  Zdt.ichriff  f.  d. 
ges.  Medicin,  of  which  he  was  one  of  the  editors.  His  contriiiutions 
relate  to  blepharoplasty,  the  non-mercurial  treatment  of  syphilis,  the 
treatment  of  orchitis  by  compression,  the  torsion  of  arteries,  the  forceps 
and  vaginal  speculum  known  by  his  name,  etc. 

George  Mojsisovics  (17!t9-l'SUU),  a  Hungarian,  studied  in  Budapest 
and  Vienna  and  graduated  in  1826.  In  1828  he  became  assistant  in  the 
surgical  school  at  Vienna,  and  in  1832  first  surgeon  of  the  General 
Hospital.     He  })ublished  nothing  of  any  importance. 

George  P.  Holseher  (1792-1852)  studied  at  Gottingen,  and  in  Lon- 
don under  Astley  Cooper,  and  settled  in  Hannover,  where  he  became  a 
teacher  in  the  surgical  school  and  editor  of  the  Hannnvcrxche  Amuden 
fur  ilie  gcminintc  Hedkuiulc  (183(J-47).  His  publications  were  almost 
entirely  journal  articles. 

Traugott  Willi.  Gustav  Benedict  (1785-1862)  studied  at  Leipzig,  grad- 
uating in  1810,  and  in  1812  became  professor  at  Breslau,  where  he 
aeijuired  a  reputation  as  an  ophthalmologist.  His  principal  surgical 
publication  is  his  Lchrbuidi  dcr  ul/grimincn  Chirurgic  und  Oprratioiinlchre 
(1842). 

The  next  group  ot  German  sui'geons  to  be  noted  includes  von  Lang- 
enbeek,  Stromeyer,  Heyfelder,  von  Pitha,  Schuh,  von  Bruns,  Giinther, 
Middledor]>f,  Busch,  Linhart,  Wagner,  and  Baum. 

Bernard  Kudolph  Konrad  von  Langenbeck  (1810-87),  the  most  dis- 
tinguished German  surgeon  of  the  nineteenth  century,  took  his  doctor's 
degree  at  Gottingen  in  1835,  became  ])rofessor  of  surgery  at  Kiel  in 
1842,  and  succeeded  I)ictl'cnl)ach  in  the  chair  of  surgery  at  Berlin  in 
1847.  In  conjunction  with  his  pupils,  Billroth  and  Gurlt,  he  established 
the  Arohiv  fur  klinische  Chirurgie  in  1861,  a  journal  which  has  con- 
tained the  most  important  contributions  tt)  surgery  made  by  German 
surgeons  since  that  date,  and  he  was  the  founder  of  the  Dcidschc  Gescll- 
schuft  fur  Chirurgic  in  1872.     Langenbeck  wrote  no  mamial  or  system 


122  THE  irrsTonv  and  literature  of  surgery. 

of  siirjfcry,  but  contriljutcil  niiincroiis  jjupcrs  to  the  Archiv  fur  klhmche 
Chlran/ie,  liis  largest  work  beinjj'  his  Chirurgischc  Beobuchtiuigen  cms  dan 
Kriec/c  (251  pp.  8vo,  Berlin,  1874).  His  operations  and  improvements 
of  the  teehnieal  methods  of  surgical  o|)erations  are  too  numerous  to 
mention.  Some  of  tiie  most  im])ortant  of  tiiem  relate  to  plastic  surgery 
of  tlie  nose  and  of  tlie  liard  palate,  and  to  o})eration8  for  tumors  at  the 
base  of  the  cranium,  for  removal  of  tiie  tongue,  etc.  His  greatest  con- 
tril)ution  to  surgery,  however,  has  been  his  pupils,  among  whom  may  be 
numbered  nearly  every  prominent  surgeon  in  Germany  of  the  present 
day. 

Georg  Friedrich  Louis  Stromeyer  (1804-7(1),  son  of  Chr.  Fr.  Stro- 
meyer,  surgeon  to  the  king  of  Hannover,  studied  at  Hannover,  Gottin- 
gen,  and  Berlin,  and  graduated  in  182G.  In  1829  he  Ix'gan  to  teach 
in  the  surgical  school  at  Hannover,  in  1838  succ'ceded  Jaeger  as  pro- 
fessor of  surgery  at  Erlangen,  in  1842  accepted  the  same  chair  in  Frei- 
burg, and  in  1847  succeeded  Jjangenbeck  at  Kiel.  He  became  surgeon- 
general  of  the  Schleswig-Holstein  army,  serving  in  the  war  of  1849, 
and  surgeon-general  of  the  Hannoverian  army  in  1854,  serving  in  tlie 
war  of  18(i(J.  His  chief  contributions  to  the  art  were  connected  with 
orthoptedic  surgery  and  tenotomy,  and  especially  with  resections  in 
military  surgery.  He  performed  subcutaneous  section  of  the  tendo 
Achillis  in  1831,  being  the  first  after  Delpech  to  do  so.  His  ])rinci])al 
pul)lications  were  Beit  rage  znr  ojicrdfircu  Orlhojiadik  (1838),  Jldiidhiich 
<lrr  Chirnrgic  (2  vols.,  1844—48),  and  Md.rimeii  dcr  Kricgx/iri/kiiiixt  (1  855). 

.lohann  Ferdinand  Heyfelder  (1798-18(j9),  student  at  Berlin,  Wiirz- 
Inirg,  and  Breslau,  graduating  in  1820,  in  1841  .succeeded  iStromeyer  as 
]n-ofessor  of  surgery  at  Erlangen,  which  position  he  resigned  in  1854. 
The  latter  part  of  his  life  was  spent  in  St.  Petersl)urg.  He  was  a 
learned  surgeon,  a  skilful  ojierator,  a  teacher  of  great  reputation,  and  a 
viiluminous  writer  uj)on  many  subjects  besides  surgery.  He  is  best 
known  by  his  treatise  Uc/jer  lic.iectioncn  uiid  Amputationen  (1854), 
M'hieh  is  a  standard  work  upon  the  subject.  His  son,  Oscar  Heyfelder 
(1828-?),  studied  at  Heidelberg  and  Erlangen,  graduating  in  1851, 
and  entered  the  Russian  army  medical  service  in  1859.  He  ])ublished 
Lchrbifrh  (Icr  BcKcrtioiicii  (2d  ed.  18(53,  and  translated  into  French  in 
the  same  year),  KrIcgKchirargischcs  ^'(t<h'  Jlcctun  (1874),  and  numerous 
articles  in  the  journals. 

Franz  von  Pitha  (1810-75),  a  native  of  Bohemia,  studied  at  Prague, 
graduating  in  1836,  and  in  1843  succeeded  Fritz  as  professor  of  .surgery 
in  the  University  of  Prague,  in  which  position  he  soon  obtained  a  high 
re])utation  as  a  teacher.  In  1854  he  accepted  the  cliair  of  surgery  in 
the  jMedico-chirurgical  .Iose|>lis  Acatleniy  in  Vienna,  re-estalilished  for 
the  purpose  of  training  medical  officers  for  tiie  Austrian  army.  His 
name  is  best  known  in  connection  with  the  Handbuch  der  aUgemeineu 
%md  speciellen  Chirurgic,  edited  by  Billroth  and  himself  (1865-82).  He 
was  a  skilful  diagnostician  and  operator  and  a  cultured  and  polished 
gentleman. 

Franz  Schuh  (1804-65)  studied  in  Vienna,  graduating  in  1831, 
became  surgeon  to  the  General  Hospital  in  A'ienna  in  1837,  and  pro- 
fessor of  surgery  in  1842.  He  was  an  excellent  practical  teacher  and 
writer,  aided  much  in  increasing  the  reputation  of  the  school,  and  con- 


THE  HISTORY  ASD  LITERATURE  OF  SUR(JERY.  123 

tributed  niinuTous  papers  to  tlie  journals.  His  itrincipal  l)(>oks  are — 
Uchvr  die  Erkcnidnhn  der  Pscudojihixiaen  ( ISol),  I'ldholoijir  und  Therapic 
der  P-'scudoplaKincn  (1854),  ami  AbhandlniHjen  avti  dcin  Hvbhie  der  (1il- 
rurgie  und  Operationskhre  (published  after  his  death,  in  lcS67). 

Victor  von  Bruns  (1812-83),  student  at  Tiibingcn,  graduating'  in 
1836,  Ijecame  professor  of  surgery  at  Tiibingen  in  1843,  whicli  jxisi- 
tion  he  held  until  1882.  He  was  one  of  the  founders  of  modern  lar- 
yngologv,  and  was  the  first  to  remove  a  laryngeal  growth  through  tJie 
natural  passages.  His  prineipal  works  are — Vhirurgixvhcr  At/as  (fob, 
1853-60),  Haadbuch  der  praldische^i  Chirurgie  (2  vols.,  1854-59),  Die 
Lari/ngoxkopie  und  die  laryngoskopisclie  Chirurgie  (1865),  Chirurgisehc 
Heilinittellehre  (2  vols.,  1868-73),  Die  galmnokaudisclu'ii  Apparate,  etc. 
(1878),  and  Die  Ainpufafion  der  Gliedmassen  dnrch  Zirkelxi:hniH  init 
vordcrem  Haidhippen  (1879). 

Gustav  Biedermann  Giinther  (1801-66)  studied  at  Ijeipzig,  graduat- 
ing in  1824,  and  in  the  following  year  became  an  assistant  to  Frioke  in  the 
General  Hospital  at  Hamburg.  In  1831  he  was  appointed  professor  of 
surgery  in  Kiel,  and  in  1841  accepted  the  same  position  at  Leipzig. 
He  was  a  good  anatomist  and  a  careful,  jjainstaking  teacher,  but  was  not 
distinguished  as  an  operator.  His  principal  work  is  his  Lvhre  von  den 
blutigen  Opendionen  uin  menseh/irhen  Korper  (4to,  1859-65). 

Albrecht  Theodor  Middeldorpf  (1824-68)  studied  at  Breslau  and 
Berlin,  graduating  in  1846,  and  in  1856  became  professor  of  surgery  at 
Breslau.  He  introduced  the  use  of  the  galvano-cautery,  made  improve- 
ments in  the  treatment  of  fractures  and  of  gastric  fistula,  and  was  one 
of  the  best  clinical  teachers  of  his  time.  His  principal  publications  are 
— Beiirdge  .sar  Lehre  von  den  Knochcnbriiohen  (1853),  Die  Galvano- 
caustik  (1854),  Ueberblick  iiber  die  Akidopeiradik  (1856),  and  Co)n- 
mentatio  de  fiatulin  nentriculi  externis,  etc.  (1859). 

Carl  David  Wilhelm  Busch  (1826-81),  son  of  the  cclclirated  obstet- 
rician Dietrich  Willi.  Heinr.  Busch,  studied  in  Bei-lin,  graduating  in 
1848,  and  after  extensive  travels  became  an  assistant  in  Langenbeck's 
clinic  in  1851.  In  1854  he  accepted  a  call  to  Bonn  as  professor  of 
clinical  surgery,  and  remained  there  until  his  death.  He  was  a  volu- 
minous writer  and  made  valuable  contributions  to  the  literature  of  gun- 
shot wounds,  fractures  and  dishjcations,  diseases  of  the  joints,  plastic  sur- 
gery, and  hernia,  the  majority  ajipearing  in  periodicals  and  transactions. 
His  Lehrbueh  der  Chirurgie  (2  vols.,  1857-69)  was  his  princij)al  work. 

Wenzel  von  Ijinhart  (1821-77),  the  son  of  a  surgeon,  studied  in 
Vienna,  graduating  in  1844  ;  became  an  assistant  of  Dumreicher,  and 
in  1856  accepted  a  call  to  Wiirzburg  as  professor  of  clinical  surgery. 
He  was  a  skilled  anatomist  and  ojicrator  and  an  excellent  teacher.  His 
principal  works  are  his  Compendium  der  ehiriirgiaehen  Operationslehre 
(1856;  4th  ed.  1874)  and  Vorh'xungen  iiber  Vaierleibn-Hernien  (1866; 
new  ed.  1882). 

Carl  Ernst  Albrecht  Wagner  (1827-70),  son  of  a  celebrated  physi- 
cian, studied  in  Berlin,  graduating  in  1848;  became  an  assistant  in 
Langenbeck's  clinic,  surgeon  to  tiie  hospital  in  Dantzig  in  1853,  and  in 
1858  professor  of  surgery  in  Kiinigsberg,  where  he  acquired  great  re])u- 
tation  as  a  teacher. 

Wilhelm    Bauni    (1799-1883)    studied    at    Konigsberg   and    Berlin, 


124  titt:  msroRY  and  literature  of  surgery. 

graduatino-  in  1822;  contiiiiu'd  liis  studies  in  Vienna,  Ijdiidon,  and 
Pariy ;  iu  I80O  became  surgeon  in  charge  of  the  municipal  liospitid  at 
Dantzig ;  in  1842  accepted  the  position  of  professor  of  surgery  at 
Greifswald ;  and  in  1849  tooiv  the  same  chair  at  GiJttingen,  from  wliich 
he  retired  in  1867.  He  was  a  learned  man  and  a  good  teacliw',  but 
published  nothing. 

To  this  period  also  belong  Zeis,  Stilling,  and  Heine. 

Edward  Zeis  (1807-68),  a  native  of  Dresden,  studied  at  Leipzig, 
Bonn,  and  Munich,  graduating  at  Leipzig  in  1832,  after  which  he 
settled  in  Dresden.  From  1844  to  1850  he  was  professor  of  surgery  at 
Marburg,  at  the  end  of  which  ])eriod  he  returned  to  Dresden  and  i)ecame 
surgeon  to  the  city  hospital.  His  principal  publications  are — HdmUmck 
(ler  plastischcii  Chtrutr/ie  (1838)  and  Die  Literatur  unci  Geschichte  der 
plastlachcn  Chirurgie  (1863-64). 

Benedict  Stilling  (1810-79)  studied  at  Marburg,  graduating  in  1833, 
and  became  assistant  in  the  surgical  clinic.  Soon  after  he  settled  in 
Cassel,  where  he  remained  for  the  rest  of  his  life.  He  is  much  better 
known  as  a  physiologist  and  investigator  of  the  nervous  system  than  lie 
is  as  a  surgeon,  but  he  M^as  the  first  ovariotomist  in  Germany,  and  Ix'tween 
1856  and  1870  published  several  papers  on  stricture  and  on  internal 
urethrotomy. 

Jacob  von  Heine  (1800-79),  of  a  liimily  of  instrument-makers  and 
orthopaedists,  student  at  Wiirzbui-g,  graduated  in  1827,  and  established 
an  orthopaedic  hospital  in  Cannstatt  which  became  celebrated.  His 
principal  publications  are — Bcob(ichti(iif/en  iihcr  Ldhvmiir/sziwtdiHje  der 
untcru  Extremitdten  und  deren  BchamUung  (1840),  Ueber  spontane  und 
congenitale  Luxationen,  etc.  (1842),  and  Spinale  Kinderldhmung  (1860). 

Here  also  may  be  mentioned  Carl  "W^illielni  von  Heine  (1838-77), 
son  of  Jacob  v.  Heine,  and  professor  of  clinical  surgery  in  the  new 
medical  faculty  of  Innspruck  in  1869,  who  wrote  on  gunshot  wounds 
of  the  lower  extremities,  hospital  gangrene,  etc. ;  August  Gustav  Herr- 
mann (1831-74)  of  Prague,  author  of  Conipjcndium  der  Krieg.'t-Chi- 
rurgic  (1870);  Fried.  Wilh.  Theodore  Ravoth  (1816-78)  of  Berlin, 
whose  most  important  works  relate  to  the  treatment  of  hernia  ;  Ernst 
Ludwig  Schillbaeh  (1825- ?)  of  Jena,  author  of  Belt  rage  zit  den 
Resectionen  der  Knoeheii  (1858-60);  Hermann  Demme  (1802-67),  pro- 
fessor of  surgery  in  Berne,  and  his  son,  Carl  Hermann  Demme  (1831— 
64),  author  of  some  valuable  papers  on  military  surgery  ;  August  Burow 
(1809-74)  of  Konigsberg,  a  pupil  of  Dieffenbach,  author  of  numerous 
papers  on  ophthalmokigy,  the  open  treatment  of  wounds,  and  plastic 
surgery  ;  Hermann  Julius  Paul  (1824—77)  of  Breslau,  author  of  I>ie 
conservative  Chirurgie  (1854  ;  2d  ed.  1859)  and  Lehrbuch  der  spericUen 
Chirurgie  (1861);  johann  Balassa  (1812-69)  of  Budapest,  celel)rated  as 
an  operator  in  lithotomy  and  plastic  surgery  ;  and  Joseph  Blazina  (1812- 
85),  who  graduated  in  1841  at  Prague,  M'here  he  became  professor  of 
surgery. 

Between  1850  and  the  present  time  the  leading  surgeons  of  Ger- 
many, besides  those  already  mentioned,  and  those  who,  being  yet  living, 
do  not  come  within  the  scope  of  this  paper,  were  LoetHcr,  AA'ilms, 
Simon,  Thaden,  Lijcke,  Hueter,  Maas,  Leisrink,  Vogt,  Volkmann,  and 
Billroth. 


THE  HISTORY  AXD  LITERATURE  OF  SURGERY.  125 

Gottfried  Friedricli  Franz  Loefflor  (1815-74)  studied  at  tlie  Fried- 
rich  A\'illu'lin  Institut  in  Bei'lin,  and  became  one  of  the  most  distin- 
guished of  the  German  army  surgeons.  His  principal  works  are — 
Lirundsatze  unci  Regeln  fur  die  Behandlmig  der  tichusswunden  im 
Kr'iege  (1859)  and  Das  preussische  Militar  Sanitdtswesen  und  seine 
Reform  (1868-<50). 

Robert  Ferdinand  Wihiis  (1824-80)  studied  at  Berlin,  graduating  in 
1846,  and  in  1848  became  an  assistant  of  Eartels  in  the  Bethanien 
Hospital,  of  which  he  was  placed  in  charge  in  1862.  He  M^as  one  of 
the  leading  surgeons  in  Berlin,  and  was  popular  as  a  teacher,  but  wrote 
little  beyond  the  rejiorts  of  his  hospital. 

Johann  Dumreichcr  (1815-80)  graduated  at  Vienna  in  1838,  became 
assistant  to  ^Yattraann,  and  took  charge  of  .one  of  the  surgical  clinics 
in  1849.     He  wrote  very  little. 

Christoph  Jac.  Fried.  Ludw.  Gustav  Simon  (1824-76)  studied  at 
Giessen  and  Heidelberg,  graduating  in  1848,  and  at  once  entered  the 
Hessian  army,  in  which  he  became  medical  director  in  1861,  in  the 
same  year  was  appointed  to  the  chair  of  surgery  at  Rostock,  and  in 
1867  accepted  a  call  to  the  same  position  in  Heidellierg.  His  first 
jiublication  was  Ucber  Schussumuden,  etc.  (1851),  soon  after  which,  on  a 
visit  to  Paris,  he  became  accpiainted  with  Jobert's  method  of  operating 
for  vesico-vaginal  fistula,  and  on  his  return  established  a  small  hos|)ital, 
acquired  great  reputation  as  an  operator  for  such  affections,  and  published 
a  number  of  pajiers  on  the  surgery  of  the  female  genitals.  After  going 
to  Heidelberg  he  performed  the  first  operation  for  nephrectomy  in  1869, 
and  published  his  C'hirurf/ie  der  Nieren  in  1871,  the  second  part  appear- 
ing after  his  death,  in  1876.  He  was  a  bold  and  skilful  surgeon,  and 
made  numerous  improvements  in  methods  of  investigating  and  treating 
surgical  affections.  He  Avas  also  a  voluminous  writer,  but  his  publica- 
tions were  concise  monographs,  and  not  large,  systematic  treatises. 

Adolf  Georg  Jacob  von  Tliaden,  a  native  of  Holstein,  studied  in 
Heidellierg  and  Kiel,  graduating  in  185.'!,  after  which  he  was  for  two 
years  an  assistant  of  Esmarch,  and  in  1861  became  surgeon  of  the  new 
city  hospital  at  Altona.     He  was  a  skilful,  scientific  surgeon. 

George  Albert  Liicke  (1827-94),  a  native  of  Magdeburg,  studied  at 
Heidellierg,  Halle,  and  Gottingen.  He  became  assistant  to  Blasius  at 
Halle  in  1854,  and  soon  after  became  assistant  to  von  Langenbeck  in 
Berlin,  and  jirivatdocent.  In  1865  he  became  professor  of  surgery  at 
Berne,  and  in  1872  accepted  the  same  position  at  Strasburg,  where  he 
remained  until  his  death. 

Carl  Hueter  (1838-82),  son  of  a  well-known  obstetrician  of  Mar- 
burg, graduated  in  1859,  after  which  he  studied  in  Vienna,  I^ondon,  and 
Paris,  and  became  a  privatdocent  in  Berlin  and  an  assistant  of  Langen- 
beck. In  1868  he  succeeded  Simon  as  professor  of  surgcrv  at  Rostock, 
and  in  1869  accepted  a  call  to  the  same  chair  at  Greifswald.  Hueter 
was  a  scientific  surgeon,  giving  great  attention  to  pathology  and  bacteri- 
ology ;  he  was  also  a  skilful  operator,  made  many  improvements  in 
method  in  resections,  tracheotomy,  excision  of  the  rectum,  etc.,  and  \vas 
a  voluminous  writer.  His  jirincipal  works  are — Klinik  der  Gelenk- 
krankheiten  (^1870-71  ;  2d  ed.  1876-78),  Die  ulhjeiimite  Chirurgie  (1873), 
and  (Trundriss  der   Chirurgie  (1880-82). 


12()  THE  HISTORY  AXf)  LITKHATVRE  OF  SVRGEBY. 

Hermann  ]\Iaas  (l.S4"2-S())  orM<luat<'(]  at  I5reslaii  in  IHii^),  and  liccanic 
assistant  to  Mid(lc'l(li>r}>f',  and  pri\atd(iccnt,  and  in  l.STT  prut'essor  of  sur- 
gery at  Freiberg.  His  chief"  work  was  his  Kriegschirwr/ische  Beitrage 
cms  (1cm  Jahre  1866  (jinblished  in  1870). 

Heinrioh  Wilh.  Franz  Lcisrink  (1845-85)  studiiMl  in  Gottingen  and 
Kiel,  graduating  in  18()8,  and  settled  in  Hamburg,  where  lie  beeanie 
distinguisheil  as  a  surgeon  and  I'ontribnted  some  valuable  papers  to 
perioilieals.  His  most  important  work  was  Die  inodcnie  Radikal- 
Opcmtion  der    Uiitcrkilmbruche,  einc  statistlsche  Arbeit  (1885). 

Paul  Fried.  Immanuel  Vogt  (1849-85)  studied  at  Greifswald,  grad- 
uating in  1865,  and  in  1882  succeeded  Hueter  as  professor  of  surgery. 
PI  is  principal  works  M'cre — TJie  ehirurgixchcn  Krcaiklicitcn  der  oberen 
Ed'treiiiiti'iten  (1881)  and  Mittheilungen  aus  der  Chirurc/ischen  Klinik  in 
Greifm-ald  (1884). 

Eichard  von  Volkmann  (1830-89),  son  of  Alfred  Wilhelm  Volk- 
mann,  professor  of  anatomy  and  physiology  in  the  University  of  Halle, 
was  educated  at  Halle,  Giessen,  and  Berlin,  and  obtained  his  medical 
degree  in  1854.  He  was  an  assistant  in  the  surgical  clinic  of  Professor 
Blasius,  in  1857  became  privatdocent,  and  in  18(j7  ])rofessor  of  surgery 
at  Halle.  With  Langenlx'ck  and  Simon  he  founded  the  German  Sur- 
gical Association,  and  in  1874  s;iid  before  this  society:  "There  is  no 
such  thing  as  luck  in  surgery  :  for  every  case  of  pyaemia,  erysipelas,  and 
necrosis  after  amputation  the  surgeon  who  treats  it  nuist  be  hclil  respon- 
sible." His  contributions  to  surgery  and  to  surgical  literature  were 
numerous  and  important,  and  he  was  the  first  German  carefully  to  study 
Lister's  methods  and  to  ui-ge  their  adoi>tion  upon  German  surgeons. 
Volkmann  was  a  poet  as  well  as  a  surgeon,  but  issued  his  poems  under 
another  name,  and  few  persons  know  that  Richard  Leander,  the  German 
poet,  is  the  same  person  as  Richard  Volkmann,  the  famous  surgeon  of 
Halle. 

Theodor  Billroth  (1829-94),  a  native  of  Bergen  on  the  island  of 
Riigen,  studied  at  Greifswald,  Gottingen,  and  Berlin,  graduating  at  the 
latter  university  in  1852.  He  became  assistant  to  von  Langeubeek, 
privatdocent  in  1856,  professor  of  clinical  surgery  at  Zurich  in  1860, 
and  ])rofessor  of  surgery  in  the  University  of  Vienna  in  1867,  succeed- 
ing Franz  Schuh.  During  the  last  twenty-five  years  he  has  lieen  one 
of  the  most  celebrated  surgeons  in  the  world  as  an  investigator  in  sui'gi- 
eal  pathology,  a  bold  and  successful  operator,  a  voluminous  writer,  and 
a  clinical  teacher.  He  first  excised  the  larynx  for  cancer  in  1873,  first 
successfully  excised  a  large  portion  of  the  stomach  in  1881,  and  gave 
a  strong  impetus  to  the  progress  of  operative  surgery  of  the  intestinal 
tract.  His  lectiu'cs  on  surgical  pathology  and  therapeutics  have  passed 
through  many  editions  and  translations;  his  reports  on  clinical  surgery 
were  translated  into  English  in  1881,  and  the  total  number  of  his  pub- 
lished books  and  papers  was  about  one  hundred  and  forty. 

The  history  of  surgery  in  Denmark  is  merely  the  old  story  of  the 
barbers  and  barber  surgeons  until  near  the  end  of  the  eighteenth  century. 
The  T^niversity  of  Copenhagen  was  founded  in  1479,  and  possessed  a 
nominal  medical  faculty  consisting  of  two  or  three  physicians  who  read 
the  works  of  Galen  and  Avicenna.  In  1559  some  attempt  was  made  to 
introduce  anatomical  studies,  and  the  young  physicians  had  to  travel  in 


THE  HISTORY  AND  LITER ATUBE  OF  SURGERr.  127 

foreign  countries  before  completing  their  studies  and  ohtaining  their 
degree.  In  1577,  Frederick  II.  issued  statutes  for  the  Collegium  Chi- 
rurgicum  of  Copenhagen,  in  which  it  was  ordered,  seeing  that  fnmi 
ancient  time  there  had  been  only  si.x  barbers  in  the  city — i.  e.  barber 
surgeons — tiiat  tlie  term  of  apprenticeshij)  should  be  three  years,  and  tlien 
the  apprentice  was  to  travel  in  foreign  countries  for  fiiur  consecutive 
years.  Ti-avclling  lithotomists  had  to  olitain  the  a])pnival  of  tiie  cor- 
poration bcf  ire  thev  were  allowed  to  operate.  Controversies  between 
the  pliysicians  and  the  barbers  occurred  as  a  matter  of  course.  In  17-'!(i, 
Simon  Krueger  (1687-1760),  a  barber  surgeon,  with  others,  founded  tlie 
"Theatrum  Anatomieo-chirurgicum,"  a  school  for  teaching  anatomy  and 
surgery,  which  ]>rospered  for  the  next  twenty-four  years,  but  was  sup- 
pressed in  1772.  In  17S.3  the  Academia  Chirurgica  was  created. 
Krueger  was  an  excellent  teacher,  but  wrote  very  little. 

Heinrich  von  Moinichen,  a  surgeon  of  Copenhagen,  published  in 
1665  his  Observatioiies  Jlledico-chirurgica',  of  which  there  were  three 
later  editions. 

Georg  Heuermann  (1722-GS),  professor  of  medicine  in  the  Uni- 
versity of  Copenhagen,  pulilished  in  1754-57  his  Abhandlunr/  dcr 
rornfhinxfcn  cliiriirf/i.iclicn  Ojicrdtioiien  am  ■menschUchen  Korjjer,  a  well- 
arranged  and  illustrated  work. 

Alexander  K.  Koelpin  (1731-1801)  graduated  in  1763,  after  which 
he  studied  under  Hunter  in  Ijondon  and  Le  C-at  in  Kouen,  and  returned 
to  Copenhagen  and  became  chief  surgeon  of  the  Friedrichs  Hospital  in 
1766.  In  1785  he  became  professor  of  the  newly-organized  surgical 
academy. 

Henry  Callisen  (1740-1824),  a  native  of  Holstein  and  a  pupil  of 
Simon  Krueger,  passed  his  preliminary  examination  in  1767,  after  which 
he  studied  at  Paris  and  under  William  Hunter  in  London.  Returning 
to  Copenhagen,  he  became  chief  surgeon  of  marines,  and  took  his  degree 
as  doctor  in  1772,  and  in  1773  succeeded  Burger  as  professor  of  surgery. 
His  Inntitufloncs  cJiirurf/icir  hodlcrnw  (1777)  and  his  Si/stcma  cliinir(/lie 
hodierna',  etc.  (1778)  passed  through  several  editions  and  translations, 
and  were  popular  text-books  until  the  beginning  of  the  nineteenth 
century. 

Adolf  Carl  Peter  Callisen  (1787-1866),  a  nephew  of  Henry  Callisen, 
graduated  at  Kiel  in  1809,  and  became  a  professor  in  the  Surgical 
Academy  in  Copenhagen  in  1817.  In  1842  he  was  professor  of  sur- 
gery in  the  university.  His  best-known  work  is  his  Medici iiIucIk's 
SchriftsfeUer-Lc.vicon  der  jvtzt  kbend.cn  Acvzte,  etc.  (in  33  vols.  8vo, 
1830-45). 

■  The  iirst  distinguished  surgeon  in  Sweden  was  Olaf  Acrel  (1717-1 806), 
who  was  chief  surgeon  of  the  Sera])him  Hosjiital  in  Stockholm  after  its 
foundation  in  1752.  '  He  becanic  jirolessor  of  surgery  in  1755,  and  his 
teachings  had  great  influence  in  the  development  of  surgery  in  Sweden. 
His  princii)al  work  is  Kirnrgiskn  Hnndelner  (Stockholm,  1759),  which 
was  translated  into  Dutch  in  1771,  and  into  German  in  1772  and  1777. 
Peter  af  Bjerkin  (1755-1818),  a  pupil  of  John  Hunter  and  a  sur- 
geon in  the  Finnish  army,  became  chief  surgeon  of  Stockholm  in  1809. 
He  was  the  greatest  Swedish  surgeon  in  the  early  part  of  this  century, 
but  wrote  nothing  of  importance. 


t^ 


128  Till-:  HISTORY  AND  LITERATURE  OF  SURGERY. 

The  first  professoi'  of  .surgery  and  obstetrics  at  the  University  of 
Christiania  was  Magnus  Andreas  Tiudstrup  (17(39-1844),  a  native  of 
Copenhagen,  who  entered  the  Norwegian  military  niedieal  service,  became 
sui'geon-gcneral,  and  in  1814  professor.     He  wrote  very  little. 

Jacob  Christian  Johan  HenriU  (Jundelach  ]Moeller  (1797-1845),  a 
native  of  Jutland,  studied  in  Copenhagen,  and  in  1842  became  professor 
of  surgery,  and  was  a  distinguished  clinical  teacher. 

Joh.  August  Liborius  (1802-187U),  a  surgeon  of  Gothenburg,  was 
well  known  in  his  day  as  a  skilled  practitioner,  and  wrote  on  the  starched 
bandage,  on  hemorrhoids,  and  on  herniotomy. 

The  leading  surgeon  of  Sweden  in  recent  years  was  Carl  Gustav 
Santesson  (1819-8()),  a  native  of  Gothenburg,  who  graduated  at  Upsala 
in  184(j,  and  became  ])rofessor  of  surgery  in  the  ytockholm  school  in 
1849,  retiring  in  LSS.").  He  contributed  a  number  of  papers  to  the 
journals,  and  published  Ojii  hoftlcdcn  och  ledbrosken  iifi  anatomiskt 
p<iflio/(H/iskt  och  chirurgiskt  hcmseende,  etc.  (Stockholm,  1849).  He  was 
a  skilled  surgeon,  a  great  teacher,  and  an  accomplished  gentleman. 

There  is  little  to  be  said  of  the  history  of  surgery  in  Ivussia  prior  to 
the  middle  of  the  nineteenth  century.  The  priests  were  the  physicians 
for  the  great  mass  of  the  people,  but  a  few  medical  men  ^\•ere  brought 
from  other  countries  during  the  sixteenth,  seventeenth,  and  eighteenth 
centuries  for  the  service  of  the  court.  Among  these  was  Bidloo,  who 
induced  Peter  I.  to  found  a  medico-chirurgical  college  and  hos]iital  in 
the  early  part  of  the  eighteenth  century.  In  1768,  Simon  Zybelin  was 
professor  of  anatomy  and  surgery  in  the  lTni\-ersity  of  Moscow,  and  in 
1812,  Andreas  Sydoratzky  (1788-1815)  was  a  teacher  of  surgery  in  the 
same  university,  but  no  record  of  their  work  is  accessible. 

Leo  Nagumowitsch  (1792-1815),  an  army  surgeon,  published,  in 
Russian,  in  1832,  a  handbook  on  the  treatment  of  gunshot  wounds,  and 
Joseph  Czekierski  (1777-1826),  a  surgeon  of  Warsaw  and  professor  of 
surgery  in  the  medical  faculty  created  in  1809,  published  a  manual  of 
surgery  (4  vols.,  1817-18). 

Elias  Bujalski  (1789-1864),  anatomist  in  the  Military  Medico-chirur- 
gical School  at  St.  Petersburg,  published  his  Tabulae  unatomko-chiru r- 
gicne  in  1828  and  again  in  1852. 

Christian  Salomon,  jtrofessor  of  surgery  at  St.  Petersburg,  published 
his  handl)ook  of  operative  surgery  in  Kussian,  in  two  volumes,  in  1840. 

The  first  distinguished  Russian  surgeon  was  Nikolaus  Iwanowitsch 
Pirogofif  (1810-81),  who  studied  at  Moscow  and  Dorpat  and  obtained 
his  degree' in  1832,  after  Avhich  he  studied  in  Berlin  and  Gottingen  for 
two  years.  On  his  return  he  gave  lectures  on  sm-gery  at  Dorpat,  being 
the  first  Russian  professor  there.  After  five  years  in  I>or])at,  in  1840, 
he  was  appointed  ])rofcssor  of  surgery  in  the  Medico-chirurgical  Academy 
of  St.  Petersburg.  His  attempts  to  improve  the  sanitar}-  condition  of 
the  military  hospital  connected  \vith  the  academy  created  much  ill-feel- 
ing, and  for  a  time  he  was  considered  and  treated  as  insane.  During 
the  Crimean  War  he  was  active  at  Sevastopol,  and  incurred  ill-^\•ill  by 
his  deHunciation  of  the  abuses  connected  with  the  Russian  military 
administration  during  the  siege,  the  rcsidt  of  which  was  that  he  was 
compelled  to  resign  his  professorship  in  the  academy  at  St.  Petersburg. 
His  contributions  to    surgery  ^\•ere  numerous    in    relation    to   gunshot 


THE  HISTORY  AND  LITERATURE  OF  SURGERY.  129 

wounds,  amputations,  and  the  surgery  of  bones,  and  his  name  is  con- 
nected with  a  method  of  ostcophistic  amputation  through  the  foot  devised 
by  him  in  1854.  The  list  of  his  publications  is  a  long  one,  the  most 
important  being  his  Rcchcrohes  prutlques  ct  physioloffiques  sur  F etherisa- 
tion (1847);  I'cqijjort  medical  d'Kii  voyage  au  Caueasr,  contenant  fa 
statiftfiqiie  compuraiiee  des  ainputatioiiit,  etc.  (1849) ;  Anatome  fopne/rapliica^ 
•sectionibus  per  corpus  huinaiium  conyelatxim ,  etc.  (fob,  1852-59) ;  Chirur- 
ffische  Anatomie  der  Arterien-staemvie  und  Fascien  (1861);  and  Grund- 
ziiffe  der  allgemeinen  Kriegsclnrnrgie  (1864). 

Little  is  known  of  the  Russian  surgeons  who  wrote  only  in  Russian, 
for  veiy  few  of  their  worlds  have  been  considered  worth  translating. 

Ivan  Rklizky  (1805-61),  professor  of  clinical  surgery  at  St.  Peters- 
burg, in  1847  jniblished  a  treatise  on  operative  sui'gery  in  Russian,  of 
which  there  were  two  later  editions. 

Peter  Dubovizki  (1815-67),  professor  of  surgery  at  Kasan,  in  1837 
published  a  treatise  on  hemorrhage,  and  one  on  litliotinpsy  in  1838. 

Sablozky-Desjatovski  (1816-82),  professor  of  surgery  at  the  Medical 
Academy  of  St.  Petersburg  in  1842,  wrote  on  hernia,  diseases  of  the 
testicle,  and  venereal  diseases. 

Polycarp  Girsztowt  (1827-77)  studied  in  St.  Petersburg,  was  an  army 
surgeon  in  the  Crimea  in  1853-56,  and  became  professor  of  surgery  in 
Warsaw  in  1860.  He  contributed  to  periodical  literature,  but  wrote  no 
special  work  of  any  importance. 

Hippolyt  Korzeniowski  (1827-79)  studied  at  St.  Petersburg,  became 
professor  of  surgery  in  Warsaw  in  1868,  and  professor  of  surgery  in  St. 
Petersburg  in  1871. 

Karl  Daniel  von  Haartman  (1792-1877)  was  professor  of  surgery 
and  obstetrics  in  the  University  of  Hclsingfors  from  its  foundatiou  in 
1833.     He  published  Casus  chirurgici  in  1815. 

One  of  the  most  distinguished  and  best  known  of  modern  Russian 
surgeons  was  Julius  Szymanowsky  (1829-68),  a  native  of  Riga,  who 
studied  at  Dorpat,  graduating  in  1856.  In  1858  he  went  to  Helsingfors 
as  assistant  professor  of  surgery,  and  in  1861  accepted  a  call  to  Kicw, 
where  he  acquired  a  great  reputation.  He  was  a  skilful  operator  and  an 
excellent  teacher.  His  principal  publications  are  Der  Gypsverband  init 
besonderer  Beriicksichfiguug  der  Militiirchirurgie  (1857)  and  a  treatise  on 
operative  surgery  in  Russian  (1864-65),  of  which  the  first  part  was 
translated  into  German  and  published  in  1872. 

Carl  Reyher  (1846-90),  a  native  of  Riga,  studied  at  Dorpat,  gradu- 
ating in  1871,  became  an  assistant  of  von  Bergmanu,  and  privatdoccnt, 
entered  the  Russian  army  medical  service,  and  became  a  distinguished 
surgeon  and  teacher  in  St.  Petersl)ui-g.  His  principal  pulilications 
relate  to  antiseptic  methods,  diseases  of  the  joints,  laryngotomy,  and 
gunshot  wounds. 

Upon  the  establishment  of  the  Spanish  rule  in  Mexico  the  medical 
system  of  Spain  was  estal)Iished  with  it,  including  the  barbers  and  the 
barljcr  surgeons.  The  first  provision  for  the  examination  of  physicians 
and  surgeons  appears  to  have  been  made  in  1646,  being  a  l)oard  com- 
jxised  of  three  persons,  two  of  whom  were  physicians  connected  with 
the  university.  From  this  date  to  1700  it  is  reported  that  forty-seven 
physicians,  one  surgeon,  three  apothecaries,  and  eighteen  barbers  were 

Vol.  I.— 9 


130  THE  HISTOJRY  AND  LITEBATUEE  OF  SURGERY. 

examined  and  .iiitlioiized  to  ])ractise.  Evidently  tlic  l)art)crs  iiad  the 
greater  part  111'  tlio  siirijical  ])raetice.  Tii  1742  it  was  ordered  that  no 
surgeon  siiould  inidertake  to  ])raetise  niedieine  iKir  to  give  [)nrgatives  or 
emetics  or  diaphoretics  or  other  drugs,  and  tiuit  no  apotiiecary  siiduid 
put  up  prescriptions  of  a  surgeon  for  sucli  drugs.  In  short,  it  is  the 
old  story  of  an  attempt  by  the  physicians  to  suppress  the  surgeons.     In 

1719  it  Mas  ordered  that  in  the  examination  of  the  surgeons  no  one 
should  be  approve<l  wlm  had  not  seen  some  practice  in  hospitals,  and  in 

1720  all  the  jiraetitioners  of  medicine,  surgery,  anatomy,  and  algeijra 
were  notified  of  the  necessity  of  passing  this  examination.  (By  "  algel^ra  " 
here  is  meant  "  bone-setting.")  (See  "  Historia  de  la  Medicina  de 
1G46-1700,"  by  Dr.  Eeyes,   Ckmeta  Mkliea  de  lle.vico,  1865-66.) 

For  a  long  time  after  the  first  settlements  on  the  Atlantic  coast  of 
North  America  very  few  educated  physicians  were  among  the  immi- 
grants. The  clergy  included  many  men  of  learning,  talents,  and  piety, 
and  some  distinguished  lawyers  accepted  ottiees  in  the  new  colonies,  but 
there  was  little  attraction  for  skilled  physicians.  Some  of  the  so-called 
"ship  surgeons"  remained,  having  commenced  by  practising  on  shore 
Avhile  their  vessels  were  in  port.  The  following  extract  from  the  Dutch 
records,  dated  February  2,  1652,  contains  a  notice  of  these  barber  sur- 
geons : 

"On  the  petition  of  the  C'hirurgeons  of  New  Amsterdam,  that  none 
but  they  alone  be  allowed  to  shave  ;  the  Director  and  Council  understand 
that  shaving  doth  not  appertain  exclusively  to  ehirurgery,  but  is  an 
appendix  thereunto ;  that  no  man  can  be  prevented  operating  on  himself, 
nor  to  do  another  this  friendly  act,  provided  it  be  through  courtesy  and 
not  for  gain,  which  is  hereby  forbidden."  It  was  then  further  Ordvr&l, 
that  ship-barbers  shall  not  be  allowed  to  dress  any  wounds,  nor  admin- 
ister any  jjotions  on  shore,  without  the  previous  knowledge  and  special 
consent  of  the  petitioners,  or  at  least  of  Doctor  La  INIontague. 

In  1662  an  act  regulating  chirurgeons'  accounts  was  passed  in  Viroinia 
{Hen.  Stat.  Va.,  vol.  ii.  p.  109). 

At  a  somewhat  later  ])eriod  in  Connecticut  the  popular  feeling  seems 
to  have  been  rather  in  favor  of  ignorance  in  a  medical  man,  if  we  may 
judge  from  the  tact  that  in  1766  the  physicians  of  Litchfield  county, 
having  endeavored  to  form  a  medical  association  and  having  applied  for 
a  charter  for  that  purpose,  were  refused  by  the  General  Assembly  on  the 
ground  that  it  would  form  a  monopoly,  and  that  as  to  quacks  and  ignorant 
men  it  was  shown  that  they  never  administered  any  jihysic  without  the 
prayers  of  the  minister  (which  cannot  be  said  of  the  I'ducated  physicians), 
and  that  no  medicine  can  be  serviceable  without  the  blessing  of  God. 
(See  Peters'  General  History  of  Connecticut.) 

In  the  early  days  of  New  England  medicine  was  in  its  primitive 
stage,  being  in  the  hands  of  the  clergy.  The  earliest  practitioners  or 
writers  on  medical  subjects  were  clergymen,  many  of  whom  had  regu- 
larly studied  medicine  in  order  to  fit  themselves  for  the  duties  of  their 
new  field,  just  as  some  of  those  intending  to  be  missionaries  do  at 
the  present  clay.  For  example,  Charles  Chauncy,  the  second  president 
of  Harvard  College,  graduated  in  both  divinity  and  medicine  at  Cam- 
bridge, and  is  said  to  have  lieen  of  the  opiniiin  that  there  ought  to  be  no 
distinction  between  them,  educating  his  six  sons  in  both  professions. 


THE  HISTORY  AND  LITERATURE  OF  SURGERY.  131 

The  first  printed  document  relatini;  to  medicine  issued  in  New  Eng- 
land is  by  a  clergyniaii,  Tiioraas  Thatcher,  who  came  to  this  country  in 
1685.  It  is  a  broadsicU'  sheet  or  poster  lieaded  "Brief  Kule  to  Guide 
tlie  Common  People  of  Xew  England  How  to  Order  Themselves  and 
Theirs  in  the  Small  Pocks  or  Measels."  This  is  usually  said  to  be  the 
first  medical  work  pul^lishcd  in  ^\.merica,  but  several  were  printed  in 
Mexico  during  the  sixteenth  century,  as,  for  example,  Alphonso  Lopez 
de  Hlnojoso  summa  y  recopikicioii  de  cirugia  con  un  arte  para  Hnngrar 
y  e.r((mcn  de  Bnrberos:  To  aiiadido  en  esta  Kecunda  edltione,  el  orir/in  y 
■nacimiento  de  las  reuinas  [etc.].     (Mcxici,  159o,  4to.) 

The  first  methodical  attempt  at  the  regulation  of  i)ractice  appears 
to  have  been  made  by  Virginia  in  1736  in  an  act  regulating  fees  and 
the  accounts  for  the  practice  of  physic.  This  fixed  the  fee  for  the  ordi- 
nary surgeons  or  apothecaries  at  five  shillings  a  visit  M'ithin  five  miles, 
and  ten  shillings  within  ten  miles,  but  those  persons  who  have  studied 
physic  in  any  university  and  taken  a  degree  therein  are  allowed  douljle 
these  rates. 

In  1760  an  act  was  jjassed  by  the  city  of  New  York  forbitlding  any 
one  to  practise  as  a  physician  or  surgeon  in  said  city  until  he  shoulil  have 
been  examined  and  approved  by  a  board  composed  of  "  one  of  his  Maj- 
esty's council,  a  judge  of  the  supreme  court,  the  attorney-general,  and 
the  mayor,"  who  may  call  in  to  their  assistance  such  person  or  persons 
as  they  think  fit.  A  similar  law  was  passed  in  New  Jersey  in  1772,  the 
examiners  being  any  two  of  tlie  judges  of  tiie  supreme  court.  In  Mary- 
land, the  District  of  Columbia,  and  South  Carolina  the  business  of  exam- 
ination and  licensing  was  placed  in  the  hands  of  the  medical  societies. 
The  distinction  between  jjhysieian  and  surgeon  soon  disapjjcared,  and 
there  is  no  trace  of  separate  organizations  for  these  two  classes  of  prac- 
titioners. 

The  majority  of  the  regidarly  educated  physicians  in  this  country  in 
1776  were  graduates  of  the  University  of  Edinburgh,  the  first  American- 
born  graduate  of  that  school  having  been  John  Moultrie  of  South  Caro- 
lina, who  oljtaincd  his  degree  in  1749.  The  first  dissection  of  the  human 
body  in  this  country  \vas  made  in  New  York  by  Drs.  Bard  and  Middle- 
ton  in  17o().  In  17o6  a  course  of  lectures  on  anatomy  and  surgery,  with 
demonstrations  on  the  dead  body,  was  given  at  Newport,  Ivhode  Island, 
by  Dr.  William  Hunter,  a  cousin  of  John  Hunter  and  an  Edinburgh 
graduate.  The  first  regularly  organized  medical  school  was  estal)lished 
in  Philadelpiiia  by  Drs.  William  Shippen  and  John  Morgan,  both 
natives  of  I'hiladelphia  and  graduates  of  Edinburgh ;  Dr.  Shi})pen  lec- 
tured on  anatomy  and  surgery. 

Tiie  only  surgical  work  by  an  American  author  printed  in  the  United 
States  prior  to  1800  was  the  Plain,  Concise  Practical  lionarks  on  the 
Treatment  of  Wounds  and  Fractures,  by  Dr.  John  Jones  (New  York, 
1775),  reprinted  at  Philadelphia  in  the  following  year  with  Van  Swieten 
on  The  Diseases  Incident  to  Armies  and  Gunshot  Wounds,  the  whole 
forming  a  small  volume  wliicii  was 'the  manual  of  the  American  army 
siu-geons  during  the  Revolutionary  War. 

Dr.  Jolm  Jones  (1729-91),  a  native  of  New  York,  studied  in  London 
under  Pott,  in  Paris  under  Petit  and  Le  Dran,  and  in  Edinburgh  under 
Monro,  was  surgeon  with  troops  in  the  French  Colonial  War  of  1758, 


132  THE  HISTORY  AND  LITERATURE  OF  SURGERY. 

and  professor  of  surgery  in  King's  (now  C'olunihiit)  College  I'roin  its 
commencement  in  1767.  He  is  said  to  have  performed  tlie  first  opera- 
tion of  lithotomy  in  this  country.  His  book,  above  referred  to,  is,  in 
the  main,  a  compend  of  the  teachings  of  Pott  and  Le  Dran,  but  contains 
a  feworiginal  observations,  the  most  remarkable  of  which  is  a  case  of 
trephining  in  delirium  occurring  eighty  days  after  an  apparently  slight 
injury  of  the  head.  There  was  no  fracture.  After  perft)rating  the  bone 
he  opened  the  dura  mater,  but  found  nothing,  and  the  result  was  prompt 
recovery.  At  the  beginning  of  the  nineteenth  century  the  leading  sur- 
geons in  the  United  States  were  the  two  Warrens  in  Boston,  Pliysick  in 
Philadelphia,  and  Wright  Post  in  New  York. 

John  Warren  (17o.')-lS15)  was  the  first  professor  of  anatomv  and 
surgery  in  the  Medical  School  of  Harvard  University,  ^vhich  ojjened  in 
1783,  being  the  first  medical  school  in  New  England.  He  amputated  at 
the  shoulder-joint  in  1781,  extirpated  the  parotid  gland  in  1804,  and  had 
a  great  reputation  as  an  operator  and  teacher,  but  wrote  only  a  few 
addresses  and  journal  articles. 

His  son.  Dr.  John  Collins  Warren  (1778-1856),  studied  in  London, 
Edinburgh,  and  Paris,  and  returned  and  joined  his  father  in  practice  in 
1802,  becoming  adjunct  professor  in  anatomy  and  surgery  in  1806,  and 
professor  in  1815.  He  was  a  skilful  operator,  and  introduced  several 
new  operations,  such  as  excision  of  the  li\iiid  bone  in  1804  and  excision 
of  the  elbow  in  1834.  In  1837  he  published  his  Smyicd/  ohservations 
on,  iumor.-^,  chiefly  a  collection  of  cases  observed  and  treated  bv  him — 
an  important  work  for  reference.  He  was  practically  the  introducer 
of  antesthesia  in  surgical  operations. 

Philip  Syng  Physick  (1768-1837),  called  ))y  some  the  "Father  of 
American  Surgery,"  a  native  of  Pliiladel])hia,  a  ])U])il  and  personal  friend 
of  John  Hunter,  wlio  refers  to  him  in  his  treatise  on  the  blood  as  liav- 
ing  performed  many  of  the  cxjieriments  referred  to,  took  his  medical 
degree  at  Edinburgh  in  1792,  became  surgeon  of  the  Pennsylvania 
Hospital  in  1794,  and  was  appointed  in  1805  to  the  chair  of  surgery 
established  in  the  University  of  Pennsylvania  in  that  year.  His  con- 
tributions to  practical  surgery  were  numerous,  but  he  wrote  nothing, 
and  his  views  are,  for  the  most  part,  known  through  the  treatise  of  his 
nephew.  Dr.  Dorsey.  Among  these  contributions  may  be  mentioned 
the  lengthening  of  Desault's  splint  for  fracture  of  the  femur,  which 
reached  only  to  the  crest  of  the  ilium,  making  it  extend  from  the  axilla 
to  below  the  foot ;  the  internal  division  of  stricture  of  the  urethra ;  the 
use  of  the  seton  in  ununited  fracture ;  his  operation  for  the  cure  of 
preternatural  anus ;  and  the  washing  out  of  the  stomach  by  means  of  a 
gum-elastic  catheter  and  a  syringe  in  a  case  of  poisoning. 

The  first  lectures  on  surgery  in  Philadel])hia  were  given  by  Dr. 
William  Shippen  (1733-1808),  a  native  of  Philadelphia,  who  studied  in 
Leyden,  Edinburgh,  and  London,  and  was  a  special  pupil  of  William 
Hunter.  In  1762  he  gave  a  course  of  private  lectures  on  anatomy  and 
surgery  in  Philadel|)hia,  and  in  1765  became  professor  of  anatomy  and 
surgery  in  the  Medical  Dcjiartmcnt  of  the  University  of  Penns}-lvania, 
just  established. 

Wright  Post  (1766-1822),  a  native  of  New  York,  studied  in  London 
in  1784-86  under  Mr.  Sheldon,  and  was  apjiointed  professor  of  surgery 


THE  HISTORY  AXD  LITERATURE  OF  SURGERY.  133 

in  C'oliiinl)ia  College  in  1792.  He,  first  in  this  country,  performed  the 
Hunterian  operation  for  aneurism  of  the  femoral  in  1796,  ligated  the 
subclavian  on  the  outer  side  of  the  scaleni  in  1817,  and  in  1813  success- 
fully ligated  the  external  iliac,  this  being  the  second  operation  of  this 
kind.  He  was  a  skilled  anatomist  and  a  good  teacher,  but  he  wrote 
niithing  beyond  a  few  accounts  of  cases. 

1'iie  tirst  systematic  treatise  on  surgery  published  by  an  American 
author  was  the  Elements  of  surgery  of  Dr.  Dorsey  (Philadelpliia,  2  vols. 
8vo,  1813).  of  which  a  second  edition  appeared  in  1818,  and  a  third  in 
1823. 

John  8yng  Dorsey  (1783-1818),  a  native  of  Pliiladclpliia,  studied 
under  his  uncle,  Dr.  PJiysiek,  and  afterward  in  London  and  Paris,  and 
in  1807  became  adjunct  professor  of  surgery  in  the  University  of  Penn- 
svlvania.  His  book  was  a  popular  text-book  ;  its  chief  value  is  due  to 
the  fact  that  it  contains  so  much  of  t^ie  experience  of  Dr.  Physick.  In 
1811  Dorsey  successfully  ligated  the  external  iliac  for  inguinal  aneurism, 
this  being  the  first  case  of  that  operation  in  the  United  States. 

In  1819,  Dr.  Physick  resigned  as  professor  of  surgery  to  become 
professor  of  anatomv,  tlie  chair  of  surgerv  l)eing  filled  l)y  Dr.  Gibson. 
Dr.  AVilliam  Gibson  (1788-1808)  M'as  born  in  Baltimore,  Md.  He 
studied  in  Edinl)urgh,  where  he  graduated  in  1809,  was  a  pupil  of  John 
Bell,  and,  after  his  graduation,  of  Sir  Charles  Bell  in  London  ;  professor 
of  surgery  in  the  University  of  ^Maryland  in  1812,  and  jirofessor  of 
surgery  in  the  University  of  Pennsylvania  from  1819  to  1855,  wiien  he 
resigned.  In  1824  he  published  liis  In.'ifitiitcx  (iml  jjracflcc  of  surffrri/, 
which  became  a  popular  text-book,  the  eighth  edition  having  appeared 
in  1850.  He  was  the  first  to  perform  the  operation  of  ligation  of  the 
common  iliac,  which  he  did  in  1812,  and  successfully  to  repeat  the 
Ciesarean  section  on  the  same  patient,  which  he  ditl  in  1837.  His 
reports  on  rn])ture  of  the  axillary  artery  in  attempts  to  reduce  old  dis- 
locations of  the  head  of  tiie  humerus  contributed  greatly  to  his  repu- 
tation. He  formed  a  large  and  valuable  collection  of  pathological 
.specimens,  colored  drawings  of  tumors,  etc.,  some  of  which  are  now 
in  the  Army  Medical  JMuseum  at  Washington. 

The  surgeon  of  the  first  part  <>f  this  century  whose  name  is  now  best 
known  to  fame  was  Dr.  Ephraim  McDowell  (1771-1830),  a  native  of 
A^irginia,  who  studied  in  IOdinl)urgh  in  179.'!  under  John  Bell,  who  was 
then  giving  special  attention  to  diseases  of  the  ovaries.  In  1795  he 
commenced  practice  at  Danville,  Kentucky,  and  soon  became  the  lead- 
ing pliysician  of  the  West.  In  1809  he  performed  the  first  methodical 
excision  of  the  ovary  fin*  the  cure  of  tumor  of  that  organ,  and  published 
an  account  of  it,  and  of  two  other  similar  cases,  in  the  Eelcetie  Repertory 
of  Philadelphia  in  1817.  His  reports  of  the  operation  attracted  little 
attention  at  the  time,  and  the  few  pul)lished  comments  on  them  were 
mostly  expressions  of  doul)t  as  to  the  accuracy  of  his  statements ;  but 
the  paper  of  Mr.  Lizars,  "  Observations  on  the  extirpation  of  the  ova- 
ria,"  in  the  Edlnhtirf/h  Mrdiral  (mil  Siuyieal  Journal  in  1824,  made  them 
generally  known,  and  altiiough  it  was  long  after  that  date  before  ova- 
riotomy became  recognized  as  a  jn-oper  surgical  operation,  yet  the  credit 
due  to  McDowell  for  originating  it  has  never  since  been  seriously  dis- 
puted.    He  wrote  very  little  and  very  reluctantly,  and  was  not  a  teacher 


134  THE  HISTORY  AND  LITEIiATURE  OF  SURGERY. 

in  any  sciiool,  but  his  luinic  stands  hioh  in  tlie  list  of  the  great  surgeons 
of  America. 

Another  distinguislied  surgeon  of  tliis  period  was  Dr.  Nathan  Smith 
(1 7(32-1 829),  a  native  of  Massaehusetts,  wlio  studied  in  the  Harvard  Medi- 
eal  Seiiool,  in  Edinlturgii,  and  in  Li)ii(h)n,  and  in  171)7  founded  a  medical 
sciiodl  in  connection  witli  Dartmouth  Cullege.  In  181.3  he  l)ecame  pro- 
fessor of  medicine  and  surgery  in  Yale  College.  He  was  tlie  second 
person  to  perform  ovariotomy  in  this  country,  which  ho  did  in  July, 
1821,  without  any  knowledge  of  the  work  of  McDowell.  He  performed 
the  first  amputatiim  at  the  knee-joint  in  the  United  States  in  1824,  first 
used  the  trejihine  in  loealizeil  inflammation  and  al)seess  of  the  shafts  of 
the  long  bones,  and  introduced  the  manipulation  method  in  the  treatment 
of  dislocations  of  the  hip-joint.  He  wrote  little,  but  an  account  of  his 
methods  and  practice  is  given  in  a  little  book  entitled  2IaJical  and  sur- 
gical memoirs,  edited  by  his  son,  Nathan  R.  Smith  (published  at  Balti- 
more in  1831).  It  contains  an  excellent  paper  on  necrosis,  a  description 
of  an  improved  apparatus  for  the  treatment  of  fractures  of  the  femur, 
remarks  on  dislocations  of  the  hip,  etc. 

Some  bold  operations  were  performed  in  these  early  days  Vjy  men 
who  wrote  nothing  and  of  whom  little  is  known ;  for  example,  abdom- 
inal section  for  extra-uterine  pregnancy  in  1759  by  John  Bard  of  New 
York,  and  in  1791  by  William  Baynham  ;  the  ligation  of  the  common 
carotid  in  1803  by  Mason  Fitch  Cogswell,  and  in  1807  by  Dr.  Amos 
Twitchell  of  New  Hampshire ;  the  complete  excision  of  the  clavicle  in 
LSll  by  Dr.  Charles  McCreary  of  Kentucky  ;  and  the  excision  of  a  part 
of  the  lower  jaw  by  Dr.  Wm.  H.  Deadrick  of  Tennessee  in  1810.  In 
1819,  Dr.  Wm.  C  Daniel  of  Savannah  first  employed  extension  by 
means  of  a  weight  in  the  treatment  of  fracture  of  the  femur,  but  did 
not  pul)lish  the  method  until  1.S29  (Am.  J.  Med.  Sc,  1829,  iv.  330).  In 
1823,  McGill  of  Maryland  successfully  ligated  both  carotids;  in  1824, 
Dr.  D.  L.  Rodgcrs  removed  nearly  the  whole  of  both  upper  jaws. 

Between  1820  and  1850  the  prominent  surgeons  in  the  large  cities 
were  John  C.  Warren  and  George  Hayward  in  Boston ;  Valentine 
Mott,  J.  Kearny  Rodgers,  Willard  Parker,  Alfred  C.  Post,  and  John 
Watson  in  New  Y'ork  ;  W.  Gibson  (above  referred  to),  J.  R.  Barton, 
George  IMcClellan,  George  W.  Norris,  and  Thomas  D.  flutter  in  Phila- 
delphia;  Nathan  R.  Smith  in  Baltimore;  R.  D.  Mussey  in  Cincinnati; 
and  Daniel  Brainard  in  Chicago. 

Valentine  Mott  (1785-1865),  a  native  of  Long  Island,  the  son  of  a 
physician,  studied  medicine  at  Columliia  College,  obtaining  his  degree 
in  1806.  He  then  A\'ent  to  London,  became  a  pupil  of  Astley  Cooper, 
returned  in  1810,  and  was  appointed  ])rofessor  of  surgery  in  Columbia 
College,  and  in  1813,  when  this  school  was  merged  in  the  faculty  oi'  the 
College  of  Physicians  and  Surgeons,  he  retained  the  chair  of  surgery.  In 
1826,  with  the  other  professors  of  the  College  of  Physicians  and  Surgeons, 
he  resigned  his  chair,  and  then  M'ith  several  of  his  associates  founded  the 
Rutgers  ]\Iedical  College ;  he  took  the  chair  of  operative  surgery  in  the 
College  of  Physicians  and  Surgeons,  which  he  resigned  in  1834  on 
account  of  his  health.  In  1840  he  was  appointed  to  the  jirofessorship 
of  surgery  in  the  Medical  Department  of  the  University  of  New  Y'ork. 
For  the  next  ten  years  his  reputation  drew  crowds  of  students  from  all 


THE  HISTORY  AND  LITERATURE  OF  SURGERY.  135 

parts  of  the  United  States.  In  1850  he  resigned  the  chair,  making 
anotlier  visit  to  Europe.  In  the  spring  of  1852  he  was  appointed 
emeritus  professor  of  surgery  in  tiie  IMedical  Department  of  the  Uni- 
versity of  the  City  of  New  York,  and  from  that  time  until  liis  death 
he  delivered  an  annual  course  of  lectures. 

]\Iott's  first  contribution  to  operative  surgery  was  the  ligature  of  the 
iiHiominate  artery  in  1818,  the  patient  surviving  for  a  long  time,  but 
finally  dying  of  secondary  hemorrhage.  The  case  established  the  prac- 
ticability, and  the  propriety  in  certain  cases,  of  the  operation.  It  was 
finally  successfully  performed  by  Dr.  A.  W.  Smythe  of  New  Orleans  in 
1864,  in  which  case  repeated  hemorrhages  also  occurred,  and  the  verte- 
bral arteiy  was  ligated  fifty-four  days  after  the  first  operation.  Mott  first 
applied  a  ligature  to  the  primitive  iliac  in  1827;  in  1828  he  entirely 
removed  the  clavicle  for  osteosarcoma;  in  1812  he  made  an  original 
operation  for  the  relief  of  ankylosis  of  the  lower  jaw.  At  the  time 
when,  in  1821,  he  excised  the  right  half  of  the  lower  jaw  in  a  case  of 
tumor  he  was  not  aware  that  a  similar  oiieration  had  been  jierformed  in 
1810  bv  Dr.  W.  H.  Deadrick  of  Tennessee,  since  no  history  of  the 
operation  was  published  until  1828.  Dupuytren  in  1812  had  removed 
a  large  part  of  the  lower  jaw  for  cancer.  Amputation  of  the  hip-joint 
was  performed  by  Dr.  Mott  in  1824,  and  it  was  for  some  time  supposed 
that  it  was  the  first  operation  of  the  kind  in  America,  but  it  is  now 
known  that  it  was  ]ierformed  by  Dr.  Walter  Brashear  of  Kentucky  in 
180(3,  but  no  aeeount  of  liis  case  had  ever  l)een  publislied.  Speaking 
of  his  excision  of  tiie  clavicle,  Dr.  Mott  called  it  his  "  ^\'aterlo(^  opera- 
tion," since  it  was  performed  on  the  17th  of  June,  the  day  before  the 
anniversai-y  of  that  battle.  In  1813,  Dr.  Charles  McCreaiy  had  removed 
the  right  clavicle  for  disease  of  the  bone,  but  it  was  little  enlarged,  com- 
paratively isolated,  and  the  operation  was  a  very  simple  one,  being 
entirely  different  from  the  extremely  difficult  operation  performed  ])y 
Dr.  Mott.  The  patient  rapidly  recovered.  Besides  the  innominate 
artery,  he  tied  the  subclavian  eight  times,  the  primitive  carotid  fifty-one 
times,  the  carotid  twice,  the  common  iliac  once,  the  external  iliac  six 
times,  the  internal  iliac  twice,  the  femoral  fifty-seven  times,  and  the 
jiopliteal  ten  times.  His  writings  consist  mainly  of  reports  of  cases 
and  operations  for  periodicals. 

J.  Kearny  Kodgers  (1793-1851),  a  native  of  New  York,  was  a  pupil 
of  Dr.  Wright  Post  and  graduated  at  the  College  of  Physicians  and 
Surgeons  in  1816.  He  studied  in  London  under  Astley  Cooper,  became 
surgeon  of  the  New  Yt)rk  Hospital  in  1822,  and  tied  the  left  subclavian 
artery  within  the  scaleni  for  aneurism  in  1845,  the  first  time  this  opera- 
tion had  l)een  perfiirmed  :  it  was  unsuccessful.  The  first  successful 
operation  of  this  kind  was  by  Dr.  Halsted  of  Baltimore  in  1892.  Dr. 
Kodgers  successfully  wired  an  ununited  fracture  of  the  humerus  in  1827 
after  excision  had  been  unsuccessfully  performed,  perhaps  the  first  ope- 
ration of  this  kind,  and  made  a  cuneiform  osteotomy  in  ankylosis  of  the 
hip  in  1840.     He  wrote  only  a  few  pajiers  for  periodicals. 

Willard  Parker  (1800-84),  a  native  of  New  Hampshire,  studied 
under  John  C.  Warren,  and  graduated  at  Harvard  in  1X30.  He  was 
for  a  short  time  professor  of  surgery  in  Berkshire  Medical  College,  and 
was  a  colleague  of  Gross  in  Cincinnati.     In  1839  he  became  professor 


136  THE  HISTORY  ASD  LITERATURE  OF  SURGERY. 

of  siivficiy  in  tlic  College  of  Ph\>iciiuis  and  Surgeons,  surgeon  of 
Bellevue  Hospital  in  1845,  and  surgeon  of  the  New  York  Hospital  in 
1856.  He  was  an  excellent  teacher  and  operator  and  greatly  beloved 
by  his  pupils,  M'ho  constituted  his  best  contributions  to  surgery.  He 
was  the  first  operator  for  strabismus  in  this  country. 

Alfred  C.  Post  (l«(.)5-85),  a  native  of  New  YorU'and  a  nepliew  of 
J)y.  \\  right  Post,  graduated  in  medicine  at  the  (.'ollege  of  Physicians 
and  Surgeons  in  New  York  in  1827,  and  continued  his  studies  in  Paris, 
Berlin,  and  Edinburgh.  He  was  one  of  the  founders  of  the  Medical 
Department  of  the  University  of  the  City  of  New  York  in  1851,  in 
which  he  was  professor  of  surgery  and  pathological  anatomy.  He 
wrote  no  systematic  treatise,  but  contributed  numerous  cases  to  the 
journals,  and  was  sjiecially  skilled  in  plastic  surgery. 

John  Watson  (1807-63),  a  native  of  Ireland,  came  with  liis  pa- 
rents to  America  in  1810,  and  graduated  in  1832.  He  became  sur- 
geon of  the  New  York  Hospital  in  1838,  where  he  first  introduced 
regular  clinical  instruction  in  surgery,  though  Dr.  Alexander  H.  Stevens 
had  previously  delivered  occasional  clinical  lectures.  He  contributed 
many  cases  to  journals,  but  wrote  no  systematic  treatises.  He  collected 
what  was  at  that  time  the  most  valuable  private  medical  library  in  this 
country,  the  greater  part  of  ^vhich,  after  his  death,  ^\•as  left  to  the  New 
York  Hos])ital  Library. 

John  lihca  Bai-ton  (1794-1871),  a  native  of  Lancaster,  Pa.,  grad- 
uated at  the  Univei-sity  of  Pennsylvania  in  181.S,  and  became  surgeon 
of  the  Pennsylvania  Hospital.  His  name  is  asst)ciated  with  a  form  of 
fracture  of  the  lower  end  of  the  radius,  with  a  special  form  of  bandage 
for  fraetin-e  of  the  jaw,  and  with  osteotomy  for  ankylosis,  which  he 
first  performed  in  1826.     In  1834  he  wired  a  fractured  patella. 

George  McClellan  (1796-1847)  M-as  a  native  of  Connecticut  and  a 
pupil  of  Dr.  Dorsev,  graduating  at  ttie  University  of  Pennsylvania  in 
1819.  He  founded  the  Jeti'erson  ^Medical  College  in  1824,  in  which  he 
was  professor  of  surgery  until  1838.  He  excised  the  body  of  the  lower 
jaw  in  1823,  excised  the  parotid  gland  for  tumors,  and  was  a  bold  and 
showy  operator.  After  his  death  liis  Ixiok  on  Principles  and  practice  of 
surr/crj/  was  published  in  1848  :  it  is  note«'orthy  only  for  the  very 
excellent  description  of  shock  which  it  contains. 

George  Washington  Norris  (1808-75)  was  a  native  of  Philadelphia, 
and  graduated  at  the  University  of  Pennsylvania  in  1830.  After  two 
years'  service  in  the  Pennsylvania  Hospital  he  went  to  Paris,  and  stud- 
ied under  Dupuytren,  A^eljjeau,  and  Roux.  He  became  surgeon  to  the 
Pennsylvania  Hospital  and  professor  of  clinical  surgery  in  the  Uni- 
versity of  Pennsylvania.  His  name  is  well  known  in  medical  literature 
from  the  extremely  valuable  statistical  contributions  to  practical  surgery 
which  he  published  in  the  American  Journal  of  the  Medical  Sciences  be- 
tween 1828  and  1854.  They  rank  among  the  best  work  of  this  kind 
which  has  ever  been  done  in  any  country,  and  his  results  are  quoted  in 
all  subse(]uent  treatises  ujion  the  subjects  upon  which  he  wrote. 

Thomas  Dent  Miitter  (1811-59),'a  native  of  Virginia,  graduated  at 
the  L'f^niversity  of  Pennsylvania,  after  which  he  studied  medicine  in 
Paris.  He  became  professor  of  medicine  in  the  Jefferson  INIedical  Col- 
lege in  1841,  and  is  celebrated  for  his  plastic  operations  for  the  cure  of 


THE  HISTORY  AXD  LITERATURE  OF  SURGERY.  137 

deformities  resulting  from  burns.  He  gave  liis  nuiscum  to  the  College 
of  Physicians  of  Pliila(leli)hia,  with  thirty  thousand  dollars  for  its  main- 
teuauce  and  the  endowment  of  a  leeturesliip.  In  this  connection  may  be 
mentioned  : 

William  E.  Horner  (1793-1853),  a  native  of  Virginia,  who  became 
a  surgeon  in  the  hospital  department  of  the  army  in  1813,  when  he  was 
twentv  vears  old  and  before  he  had  graduated.  He  iiecame  professor  of 
anatomy  in  the  University  of  Pennsylvania  in  1831,  succeeding  Dr. 
Borscy.  His  name  is  connected  with  the  Wistar  and  Horner  Museum, 
which  he  bequeathed  to  the  university,  and  also  with  tlie  muscle  \\hieh 
lie  named  the  "  tensor  tarsi."  His  contributions  to  surgery  are  to  be 
found  in  papers  in  the  American  Journal  of  the  3ferlieal  tSciences. 

R.  D.  Mussey  (17SO-1806),  a  native  of  New  Hampshire,  studied 
medicine  under  Dr.  Nathan  Smith,  and  graduated  at  the  University  of 
Pennsvlvania  in  1809.  He  was  professor  of  the  theory  and  practice  of 
medicine  at  Dartmouth,  1814;  professor  of  anatomy  and  surgery  in  the 
.same  school,  1819  ;  professor  of  surgery  in  the  ]\Iedieal  College  of  Ohio 
at  Cincinnati  in  1838  ;  and  professor  of  surgery  in  tlie  Miami  Medical 
College  in  Cincinnati  in  1852.  He  was  a  bold  operator,  and  first  tied 
both  carotid  arteries  in  1S27  for  a  large  bleeding  tumor  of  the  head,  and 
removed  the  scapula  and  clavit'lc  for  tumor  following  amputation  at  the 
shoulder-joint.  His  only  contributions  to  surgical  literature  were  in  the 
shape  of  re})orts  of  cases  in  the  journals. 

Daniel  Brainard  (1812-()R),  a  native  of  Western  New  York,  graduated 
at  the  Jeifcrson  ^Medical  College,  Piiiladcliihia,  in  1834.  He  successfully 
amputated  at  the  hip-joint  in  Chicago  in  183.S,  which  established  his 
reputation,  and  in  1.S54  ])iiblished  an  excellent  essay  on  the  treatment 
of  ununited  fractures.     He  was  the  founder  of  Rush  jMedieal  College. 

One  of  the  most  celebrated  surgeons  of  the  West  of  this  period  was 
Benjamin  W.  Dudley  (1785-1870),  a  native  of  Virginia,  who  graduated 
at  the  University  of  Pennsylvania  in  1806,  after  wliich  he  studied  in 
Paris  and  Jjoudon,  returning  to  Lexington  in  1814,  and  became  pro- 
fessor of  anatomy  and  surgery  in  the  Medical  Department  of  the 
Transylvania  University  in  1817.  His  reputation  rested  mainly  upon 
his  operations  for  lithotomy,  which  he  performed  two  hundred  and 
tM'enty-five  times  with  almost  unparalleled  success.  He  wrote  nothing 
except  a  few  short  essays,  the  first  of  which.  Observations  on  injuriei<  of 
the  head  [inelu<ling  eases  of  trephining  for  epilepsy],  M'as  pul)lished  in 
the  first  nunil)er  of  the  Transi/Zrania  Journal  of  Medicine  in  1828,  and 
is  a  very  important  paper  in  the  history  of  this  operation. 

We  now  come  to  an  e])oeh  in  the  history  of  surgery.  On  November 
3,  1846,  Dr.  Henry  J.  Bigelow  read  before  the  American  Academy  of 
Arts  and  Sciences  an  abstract  of  a  paper  which  was  published  in  full  in 
the  Boston  Medical  and  Hure/ical  Journal  of  November  18,  1846,  under 
tiie  title  "  Insensibility  during  surgical  ojierations  produced  l)v  inhala- 
tion," which  was  the  first  definite  account  of  the  method  of  produc- 
tion of  satisfactory  anaesthesia  in  surgical  operations.  W^riters  of  the 
thirteenth  and  tourteenth  centuries  had  described  the  inhalation  of  nar- 
cotic vapors  from  certain  ]ilants  for  this  ])urpose.  Sir  Humjihrv  Davy 
had  suggested  in  ISOO  that  "nitrous  oxide  may  probablv  lie  used  with 
advantage  in  surgical  ojK'rations."     ]\lr.  Hickman,  a  London  surgeon, 


138  THE  HISTORY  AND  LITERATURE  OF  SURGERY. 

had  written  in  1828  a  letter  to  Xing  Charles  X.  (which  letter  was  laid 
before  the  Academy  of  Medicine  of  Paris),  in  which  he  said  that  he  had 
discovered  the  means  of  pcrforniinii;  the  most  troublesome  operations 
without  pain  by  produciui;  insensibility  by  the  introduction  of  certain 
gases  into  the  lungs  (Archie,  (jni.  dr  tni'd.,  1st  scr.  xviii.  p.  453).  Dr. 
Crawford  W.  Long  of  Athens,  Ga.,  had  ])ro(luced  antesthesia  by  ether 
in  1842  for  the  operation  of  removing  small  tumors,  but  had  not  pub- 
lished the  results,  when  Dr.  Warren  allowed  a  dentist.  Dr.  Morton,  to 
give  ether  to  produce  insensibility  while  he  j)erformcd  a  small  opera- 
tion in  the  Massachusetts  General  Hospital. 

It  is  to  ^^^arren,  Hayward,  and  Bigelow  that  the  surgical  world  is 
indebted  mainly  for  a  sufficient,  general,  and  safe  method  of  anicsthesia. 
Morton  wanted  to  patent  his  method,  which  was  not  a  thoroughly  safe 
one  until  modified  by  Bigelow,  and  little  credit  is  due  to  him  or  to  Wells 
or  Jackson  for  the  part  which  they  then  played  in  the  Inisiness.  The 
statements  of  Dr.  Bigelow  were  readily  accc|)tcd  by  surgeons,  and  early 
in  1847  anaesthesia  was  in  general  use  througiiout  the  civilized  world. 

Nothing  like  it  had  been  known  before,  and  there  has  been  little 
improvement  in  it  since,  for  chloroform,  though  more  convenient  for 
use,  is  decidedly  more  dangerous  than  ether  in  many  cases.  Most  of  the 
great  operations  had  been  devised  and  performed  by  a  few  skilled  opera- 
tors befoi'c  the  introduction  of  anicsthesia,  but  tlu'  performance  was  not  in 
the  delilx'rate,  careful  manner  which  is  now  ■\\'oll  recognized  as  charac- 
terizing the  best  surgery,  especially  in  these  days  of  asepsis  and  anti- 
sepsis. The  influence  of  anaesthesia  upon  surgical  diagnosis  has  been 
almost  as  great  as  ujton  methods  of  operation,  for  with  its  aid  it  is  possible 
to  explore  tlie  interior  of  the  body  in  ways  that  would  be  impossible  with- 
out it.  With  its  aid  the  recent  graduate  undertakes  operations  w  liich  he 
would  not  dream  of  trying  without  it :  it  has  done  away  with  the  need  for 
some  of  the  most  special  qualifications  which  formerly  were  thought  to  be, 
if  not  indispensable,  at  least  of  great  importance  to  the  oj)erator. 

Henry  Jacob  Bigelow  (1816-90),  a  native  of  Boston,  took  his  medi- 
cal degree  in  1841,  after  which  he  spent  three  years  in  Eurojie,  most  of 
the  time  in  Paris.  In  1845  he  was  appointed  instructor  of  surgery  at 
the  Trcmont  Street  Medical  School.  In  1846  he  was  made  surgeon  to 
the  Massachusetts  General  Hosjjital,  and  in  1849  was  appointed  profes- 
sor of  surgery  in  the  Harvard  Medical  School,  the  Uvo  chairs  of  surgery 
and  clinical  surgery,  jn-eviously  held  by  Dr.  J.  C.  Warren  and  Dr. 
George  Hayward,  being  united.  He  pei'formed  the  first  excision  of  the 
hip-joint  in  this  country  in  1S52,  and  first  exi)laincd  the  mechanism  of 
the  ilco-fcmoral  ligament  and  its  importance  in  reducing  dislocations  of 
the  hip-joint.  His  chief  contribution  to  surgery  was  his  operation  of 
litholapaxy,  which  has  effected  a  great  change  in  the  treatment  of  vesical 
calculus.  He  was  a  graceful  and  dexterous  operator,  a  clear  and  epigram- 
matic teacher,  and  the  leading  surgeon  in  New  England  until  he  retire<l 
in  1882. 

The  number  of  American  surgeons  who  have  become  known  as 
inventors,  teachers,  or  writers  since  1850  is  very  large,  and  only  a 
brief  notice  can  be  given  of  the  most  prominent.  In  New  York  we 
have  had  William  H.  Van  Buren  (1819-83),  who  studied  in  Paris,  was 
an  assistant  surgeon  in  the  army  for  four  years,  in  1845  joined  Mott  in 


THE  HISTORY  AND  LITERATURE  OF  SURGERY.  139 

clinical  teaching,  became  professor  of  anatomy  in  1852,  and  professor 
of  surgery  in  the  Bellevue  Medical  College  in  186S.  His  Contributions 
to  practical  ^urgeri/  a])peared  in  1865,  and  his  work  on  Diseases  of  the 
genito-urinary  s}/sfcm  in  1874. 

Gurdon  Buck  (1807-77),  surgeon  of  the  New  York  Hospital  in  1837, 
and  of  St.  Luke's  in  1858,  made  vahiable  contributions  to  surgery  in  the 
method  of  treating  fractures  of  the  thigh  by  weight  and  pulley,  in  tlie 
plastic  surgery  oi'  the  face,  and  in  the  treatment  of  ankyhisis  of  tiie 
knee. 

James  R.  Wood  (1816-82),  the  first  to  introduce  clinical  teaching  in 
Bellevue  Hospital,  and  one  of  the  founders  of  Bellevue  Medical  College, 
was  a  bold  operator  and  a  very  popular  teacher.  He  removed  the  entire 
lower  jaw  in  a  case  of  phosphorus-necrosis,  leaving  the  periosteum  from 
M'hich  a  new  jaw  was  formed  ;  excised  Meckel's  ganglion  with  the  superior 
maxillary  l)ranch  of  the  fifth  pair  ;  and  was  one  of  the  first  in  America 
to  perform  excision  of  the  shoulder-  and  elbow-joints. 

Frank  H.  Hamilton  (1813-66),  a  native  of  Vermont,  graduated  in 
Philadelphia  in  1833;  became  professor  of  surgery  in  Buffalo  in  1844, 
and  in  the  Bellevue  Medical  College  in  New  York  in  1862.  He  pub- 
lished his  Practical  treatise  on  fractures  cnid  dislocations  (Philadelphia, 
1860)  and  his  Practical  treatise  on  militari/  surgcri/  (1861  ;  2d  ed.  1865). 

Alden  March  (1795-1869)  settled  in' Albany  in  1820  after  gradu- 
ating at  Brown  University,  Rhode  Island,  and  commenced  lecturing  on 
anatomy  in  1821,  being  the  first  lecturer  in  that  city.  He  was  professor 
of  surgery  in  the  Albany  ]\ledical  College  in  1838,  and  gave  one  of  the 
first  surgical  clinics  in  this  country.  He  made  valuable  investigations 
in  hip-joint  disease,  and  performed  a  large  number  of  surgical  operations, 
including  sixty-five  amputations  through  the  thigh  and  eleven  excisions 
of  the  lower  jaw. 

Henry  Berton  Sands  (1830-88)  graduated  from  the  College  of 
Physicians  and  Surgeons  in  New  York  in  1854;  studied  in  Paris; 
and  on  his  return  l>ecame  professor  of  anatomy,  and  then  of  surgery. 
He  was  surgeon  to  the  Bellevue  and  New  York  Hospitals  and  to  the 
Roosevelt  Hospital,  and  in  the  latter  j)art  of  his  life  was  the  leading 
surgeon  in  New  York  City.  He  was  the  first  to  operate  in  peritonitis 
due  to  perforation  of  the  appendix. 

Here  also  may  be  mentioned  J.  Marion  Sims  (1813-83),  a  native  of 
South  Carolina,  who  connnenced  practice  in  Montgomery,  Alabama,  and 
there  devised  his  mode  of  operating  for  vesico-vaginal  fistula;  he  came 
to  New  York  in  1853,  and  became  the  founder  of  modern  gyna'cology. 

The  Philadelphia  surgeons  of  this  period  who  have  finished  their 
work  are  Gross  (father  and  son),  Agnew,  Pancoast,  and  Smith. 

Samuel  D.  Gross  (1805-84),  a  native  of  Pennsylvania  and  a  grad- 
uate of  the  .Jeiferstm  Medical  College  in  1828,  after  tilling  various 
chairs  in  Western  schools  and  in  New  York  accepted  the  chair  of 
surgery  in  the  Jefferson  INIedical  School  in  1865,  from  which  he  retired 
in  1882.  He  was  a  man  of  strong  personality  and  great  influence,  an 
incessant  worker,  a  voluminous  writer,  an  excellent  teacher,  and  one  of 
tlie  most  distinguished  surgeons  of  his  time.  He  wrote  the  first 
.systematic  treatise  on  pathological  anatomy  by  an  American  author, 
made    original    experiments    on    wounds   of    the    intestines,    published 


140  THE  HISTORY  AND  LITERATURE  OF  SURGERY. 

valuahle  monographs  on  diseases  of  the  bladder  (1851;  2d  ed.  1855), 
on  foreign  bodies  in  the  air-])assages  (1854),  and  a  system  of  surgery  in 
two  hirge  vokimes  (1859  ;  (Jth  ed.  1882),  wliieli  is  an  imjiortaut  book  of 
reference. 

His  son,  Samuel  W.  Gross  (1837-89),  graduated  at  the  Jefferson 
IVIedieal  College  in  1857.  (Jn  the  oiitlircak  of  tjie  Civil  War  he  beeanie 
a  surgeon  of  volunteers,  acting  as  medical  director  in  various  depart- 
ments until  18()5.  In  1882,  on  the  retirement  of  his  father,  he  was 
elected  one  of  the  professors  of  surgery  in  Jefferson  Medical  College. 
Pie  made  numerous  contributions  to  surgical  literature  in  the  journals, 
published  a  treatise  on  Tumors  of  the  manuiiary  glands  in  1882,  a 
treatise  on  Impotence  and  sterility  in  18X1,  and  assisted  his  father  in  the 
j)re])aration  of  the  various  editions  of  his  System  of  Surgery.  He  was 
a  bold  yet  careful  operator  and  an  earnest  and  eloc|uent  lecturer. 

Joseph  Pancoast  (1805-82),  a  native  of  New  Jersey,  gradu;ited  at 
the  University  of  Pennsylvania  in  1828.  He  began  teaching  ])ractical 
anatomy  and  surgery  in  1881.  In  18.j8  he  was  elected  professor  of 
.surgery  in  the  Jefferson  Medical  College ;  in  1847,  professor  of 
anatomy  in  the  same  college.  He  published  his  Trrntine  on  operative 
surgery  in  1844  (3d  ed.  1852).  He  was  distinguished  for  his  operations 
in  plastic  surgery,  especially  for  exstro|)hy  of  the  bladder ;  devised  the 
operation  of  section  of  the  tliird  branch  of  the  fifth  pair  of  nerves  at 
its  issue  from  the  base  of  the  skull,  and  of  the  second  branch  of  the 
fifth  pair  at  the  same  place  ;  was  a  skilled  anatomist,  a  dexterous  0])e- 
rator,  and  a  popular  clinical  teacher. 

Henry  H.  Smith  (1815-90),  a  native  of  Philadelphia,  graduated  at 
the  University  of  Pennsylvania  in  1837,  after  which  he  studied  in 
London  and  Paris.  He  became  professor  of  surgery  in  the  Uni\'ersity 
of  Pennsylvania  in  1855,  and  resigned  in  1871.  His  Si/sfcm  of  opera- 
tive siirgeri/,  published  in  1853  (2d  ed.  in  1856),  contains  a  valuable 
history  of  surgery  in  the  United  States,  with  an  index  of  the  princij)al 
contributions  of  American  writers  on  subjects  connected  wuth  operative 
surgery  down  to  the  year  1854. 

Francis  Fontaine  Maury  (1840-79),  a  native  of  Kentucky,  grad- 
uated at  Jefferson  Medical  College  in  18G2;  jierformed  the  first  opera- 
tion of  gastrotomy  in  this  country,  excision  of  the  brachial  plexus  for 
painful  neuroma,  operation  for  exstrophy  of  the  bladder,  and  two  opera- 
tions for  extirpation  of  the  thyroid  gland.  He  was  surgeon  of  the 
Philadelphia  Hospital. 

Dr.  I).  Hayes  Agnew  (1818-92),  a  native  of  Pennsylvania,  grad- 
uated at  the  University  of  Pennsylvania  in  1838.  In  1852  he  became 
the  head  of  the  Philadelphia  School  of  Anatomy,  to  which  he  soon 
added  a  school  of  operative  surgcrj' ;  in  1863  he  left  this  to  become 
demonstrator  of  anatomy  in  the  University  of  Pennsylvania,  in  which 
he  became  professor  of  clinical  surgery  in  1878  and  professor  of  surgery 
in  1871.  A  highly-skilled  anatomist,  an  unusually  dexterous  o])erator, 
and  a  keen,  shrewd  diagnostician,  he  acquired  an  immense  ])ractical 
experience  in  all  forms  of  siu-gical  affections  and  treatment,  which  he 
embodied  in  his  treatise  on  the  Principles  and  practice  of  .mrgcri/,  pub- 
lished in  three  large  volumes  in  1878-83,  and  again  in  a  second  edition 
in  1889.     He  was  one  of  the  few  great  surgeons  who  have  continued  to 


THE  HISTORY  ASD  LITERATURE  OF  SURGERY.  141 

practise  medicine  as  well  as  surgery  until  the  end  of  their  career,  and 
he  did  tliis  liecause  he  believed  it  made  him  a  better  surgeon. 

J.  L.  Atleo  (1799-1885),  a  native  of  Lancaster,  Pa.,  graduated  at  the 
University  of  Pennsylvania  in  1820,  and  practised  at  Lancaster  through- 
out liis  life.  In  1843  he  revived  the  operation  of  ovariotomy,  and  with 
his  In-other  established  it  on  a  firm  basis.  He  was  the  first  successfully  to 
remove  both  ovaries  at  one  operation. 

Washington  L.  Atlec,  his  Iirotlier  (1808-78),  was  a  pupil  of  George 
McClellan,  and  performed  liis  first  operations  for  ovariotomy  in  1844. 
Tiiis  operation  he  performed  three  hundred  and  eighty-seven  times,  and 
had  more  influence  in  popularizing  it  than  any  other  man  in  this  country. 
His  most  imjKirtant  contribution  to  literature  is  on  the  diagnosis  of 
ovarian  tumors,  ])ublished  in  1873.  He  was  also  celebrated  as  an  ope- 
rator for  the  removal  of  uterine  tumors. 

Jonathan  Knight  (1789-18()4)  studied  at  the  University  of  Pennsyl- 
vania, and  became  professor  of  anatomy  and  physiology  in  the  Medical 
Institution  of  Yale  College  when  it  was  organized  in  1813.  In  1838  he 
became  professor  of  surgery,  and  held  the  chair  to  the  end  of  his  life. 

Paul  F.  Eve  (1806-77),  a  native  of  Georgia,  graduated  from  the 
University  of  Pemisylvania  in  1828.  He  studied  several  years  in 
Europe,  was  a  volunteer  surgeon  in  the  Polish  Rebellion  of  1831,  and 
became  professor  of  surgery  in  the  Medical  College  of  Georgia  in  1832, 
in  Louisville  University  in  1849,  in  the  Nashville  University  in  1850, 
in  the  Missouri  INIedical  College  of  St.  Louis  in  1868,  and  professor  of 
operative  and  clinical  surgery  in  the  University  of  Nashville  from  1870 
to  the  date  of  his  death.  He  published  ^4  collvcHon  of  rcmarbihlc  w.sc.s- 
in  tiurr/eri/  (Philadelj)hia,  1857) — a  most  useful  and  interesting  work,  and 
it  is  highly  desirable  that  a  similar  collection  should  be  made  for  the  lat- 
ter half  of  this  century. 

George  C.  Blackman  (1819-71),  a  native  of  Connecticut,  graduated 
in  medicine  at  the  College  of  Physicians  and  Surgeons,  New  York,  in 
1840,  and  for  the  next  ten  or  fifteen  years  was  engaged  in  study  in  Great 
Britain  and  in  France,  and  as  surgeon  of  an  Atlantic  packet-ship  ;  in  1855 
he  liecame  professor  of  surgery  in  the  jNIedieal  College  t)f  Ohio.  He  was  a 
skilful  diagnostician  and  anatomist,  a  bold  surgeon,  an  excellent  clinical 
teacher,  and  thoroughly  at  home  in  surgical  literature.  He  contril)uted 
largely  to  periodicals,  re-edited  Mott's  edition  of  Velpeau,  and  translated 
the  work  of  Vi<lal  on  Venereal  diseases,  but  left  no  monograph  or  sys- 
tematic treatise. 

Charles  Pope  (1818-70),  professor  of  surgery  in  St.  Louis,  Mo.,  in 
1847,  was  distinguished  as  an  operator  and  teacher,  but  wrote  very 
little. 

Elias  Samuel  Cooper  (182.3-62),  a  native  of  Oliio,  studied  medicine  in 
Connecticut  wlien  very  young  ;  began  jiractice  at  nineteen  years  of  age, 
soon  after  whicli  lie  excised  a  large  portion  of  the  lower  jaw,  and  at  the 
age  of  twenty -tliree  ojiened  a  dissecting-room  in  Peoria,  111.,  and  gave 
lectures  on  anatomy.  In  1855  he  removed  to  San  Francisco,  and  in 
1858  was  one  of  the  founders  of  the  Medical  Department  of  the  Univer- 
sity of  the  Pacific,  in  which  he  became  professor  of  anatomy  and  surgery. 
He  performed  a  number  of  the  greater  surgical  operations,  twice  ligated 
the  innominate  artery,  twice  performed  Cesarean  section,  and  repeatedly 


142  THE  HISTORY  AND  LITERATURE  OF  SURGERY. 

operated  for  ovariiin  tumors.  f)iic  of  liis  most  celebrated  operations  was 
tlie  removal  of  a  piece  of  iron  an  incii  long  and  three-quarters  of  an  inch 
thick,  whicli  the  explosion  ol'  a  ji'un-hnrrel  had  driven  into  the  chtwt 
l>eneath  and  licliind  the  heart,  and  which  had  remained  there  over  two 
months.  His  contributions  to  the  literature  of  surgery  are  found  entirely 
in  periodicals. 

Robei't  Nelson  (1794-1873),  a  native  of  Canada,  became  distinguished 
as  a  surgeon  in  Montreal,  and  especially  as  a  lithotomist ;  implicated  in 
tlie  rebellion  of  1837,  he  came  to  the  United  States,  for  a  short  time 
filled  the  chair  of  anatomy  and  surgery  at  Castleton,  A^t.,  and  Pittsfield, 
Mass. ;  went  to  California  in  1849,  and  finally  settled  in  New  York.  He 
is  the  author  of  a  pamplilet,  Gastrotoiiii/  for  the  removal  of  non-malig- 
nant tumors  from  the  abdominal  cavity  (New  York,  1864),  and  of  jiapers 
in  the  journals,  especially  in  the  Northern  Lancet,  of  which  he  was  the 
editor  'from  1850  to  LSbo. 

John  T.  Hodgen  (1824-82),  a  native  of  Illinois,  professor  of  anatomy 
in  the  Missouri  Medical  College  in  1852,  and  professor  of  clinical  and 
military  surgery  in  1872,  made  valuable  contributions  to  methods  of 
treatment  of  fractures,  and  his  splint  is  well  known. 

George  Alexander  Otis  (1830-81)  was  a  native  of  Boston,  and  gradu- 
ated in  medicine  at  the  University  of  Pennsylvania  in  1851.  He  studied 
in  Paris,  entered  the  army  in  1861,  was  curator  of  the  Army  ]\Iedical 
Museum,  and  wrote  the  first  two  surgical  volumes  of  the  Medical  and 
surgical  history  of  the  war  of  the  rebellion,  using  the  vast  material  in  a 
thoroughly  scientitic  manner. 

Moses  Gunn  (1822-87),  a  native  of  New  York,  of  Scotch  descent, 
settled  at  Ann  ^Vrlior,  Mich.,  became  jirofessor  of  anatomy  and  surgery 
in  1850,  and  ])rofessor  of  surgery  in  Rush  ^Medical  College  in  1867, 
succeeding  Brainard.  He  was  a  skilled  anatomist,  a  ])opular  teacher,  and 
wrote  a  valuable  paper  on  reduction  of  dislocations  liy  manipulation. 

John  M.  Carnochan  (1817-87),  a  native  of  Savannah,  (ia.,  a  pupil  of 
Valentine  Mott,  a  surgeon  in  New  York  City,  was  a  daring  ojx'rator. 
He  excised  the  entire  lower  jaw  in  1851  and  in  1864,  removed  IMeckel's 
ganglion  and  the  superior  maxillary  nerve  in  1856,  and  ligated  the  fem- 
oral for  elephantiasis  in  1851.  Besides  journal  articles  he  was  the  author 
of  A  treatise  on  ....  congenital  dislocations  of  the  head  of  the  femur 
(New  York,  1850,  8vo)  and  Contributions  to  opercdive  surgery  and  sur- 
gical jxdhology  (New  York,  1877-83,  4to). 

Robert  Alexander  Kinloch  (1826-91),  a  native  of  Charleston,  gradu- 
ated in  medicine  from  the  University  of  Pcmisylvania  in  1848,  after 
which  lie  studied  in  London,  Paris,  and  Edinburgh.  During  the  Civil 
War  he  was  medical  director  on  the  staffs  of  Generals  Lee,  Pemberton, 
and  Beauregard.  In  1867  he  became  professor  of  materia  niediea  and 
therapeutics  in  the  Medical  College  of  the  State  of  South  C'arolina,  and 
soon  afterward  jirofessor  of  surgery,  which  position  he  held  to  the  time 
of  his  death.  He  was  the  most  prominent  surgeon  in  his  State,  and 
Avas  the  first  in  this  country  successfully  to  excise  the  knee-joint  for 
chronic  disease  and  to  treat  fracture  of  the  lower  jaw  by  wiring  the 
fragments.  He  was  also  the  first  surgeon  to  open  the  abdomen  in  cases 
of  gunshot  wounds  in  which  there  is  no  protrusion  of  the  viscera.  His 
contributions  to  surgical  literature  were  entirely  to  medical  periodicals. 


THE  HISTORY  AND  LITERATURE  OF  SURGERY.  143 

Other  surgeons  well  known  in  their  own  States  were  George  Hayward 
(1791-lSG.S),  professor  of  surgery  in  the  Harvard  Medieal  School,  who 
published  some  valuable  surgical  reports  in  journals  and  in  a  volume  in 
1865;  Jacob  Randolph  (1796-1848),  surgeon  of  the  Pennsylvania 
Hospital,  who  introduced  lithotrity  in  America ;  Horace  A.  Ackley 
(1812-59),  professor  of  surgery  at  Cleveland,  Ohio,  1843-56  ;  Ely  Ged- 
dings  (1799-1878),  professor  of  surgery  in  Charleston,  S.  C,  the  outlines 
of  whose  lectures  were  published  in  1858;  John  Neill  (1819-80),  pro- 
fessor of  surgery  in  the  Philadelphia  College;  Ernst  Krackowizer 
(1821-75),  a  native  of  Upper  Austria,  who  came  to  New  York  in  1850, 
and  was  surgeon  of  the  Brooklyn  City  Hospital ;  Julius  F.  Miner 
(1823-86),  professor  of  surgery  in  Buffalo ;  Joseph  C.  Hutchinson 
(1827-87),  professor  of  surgery  in  Brooklyn  ;  and  Josiah  C.  Nott 
(1804-73),  professor  of  surgery  at  Mobile,  but  better  known  as  a 
writer  on  ethnology. 

The  history  of  surgery  in  the  United  States  has  been  told  by  Gross 
(Am.  Jour.  3'led.  Sc,  N.'S.,  Ixxi.  1876,  431),  and  its  triumphs  in  the 
way  of  first  operations  have  been  set  forth  by  Dr.  Dennis  {3Icdical 
Record  of  New  York,  1892,  xlii.  637-648),  and  to  these  papers  the 
reader  is  referred  for  details  \\liich  there  is  not  space  here  to  give. 

In  addition  to  anajsthesia,  ovariotomy,  and  the  foundation  of  modern 
gyntccology,  American  surgeons  have  contributed  much  to  the  art  in  the 
way  of  perfecting  apparatus  for  the  treatment  of  fractures  by  extension  ; 
of  reduction  of  (lisloeations  by  manipidation  ;  of  the  treatment  of  dis- 
eases of  the  liip  and  spine  ;  of  tlie  ligation  of  large  blood-vessels  ;  of 
the  removal  of  tumors ;  of  the  surgery  of  the  brain,  spinal  cord,  mouth, 
jaws,  kidney,  liver,  and  urinary  organs.  It  is  true  tliat  the  scattered, 
um-eported  "first  cases"  of  some  of  the  great  operations  by  early 
American  physicians  must  be  considered  as  entitling  the  individual  to 
praise  for  his  boldness  or  ingenuity  rather  than  as  "contributions  to 
surgery,"  because  it  is  not  until  such  procedures  have  been  made  known 
to  the  profession  and  become  a  part  of  surgical  literature  or  teaching 
that  they  have  become  useful  ;  but  from  the  beginning  of  the  history 
of  the  art  we  find  that  the  majority  of  the  "  first  operations "  of  all 
kinds  have  been  made,  not  by  distinguished  professors  and  famous 
authors,  but  by  men  who  were  neither  teachers  nor  authors,  and  the 
names  of  many  of  whom  are  unknown  to  this  day.  This  is  true  of 
amputations,  lithotomy,  herniotomy,  trephining,  excision  of  the  breast, 
ligation  of  a  wounded  artery,  C;esarean  section,  hysterectomy,  ovari- 
otomy, and  of  the  invention  of  many  of  the  primitive  forms  of  some  of 
the  most  important  instruments  of  the  present  day.  "  Les  petits  pro- 
phets," as  Verneuil  styles  them,  are  worthy  of  all  honor,  and  one  of 
the  objects  of  a  history  of  surgery  is  to  keep  their  names  at  least  from 
being  forgotten.  American  surgeons  have  contributed  at  least  a  fair 
share  to  tlie  common  stock  of  knowledge  in  the  past,  and  it  seems  prob- 
able that  they  will  do  still  more  in  the  near  future.  They  have  been, 
for  the  most  part,  "  practical  men  :"  it  is  only  within  the  last  twenty 
years  tiiat  the  scientific  problems  of  surgical  pathology  have  been  the 
subject  of  experiment  and  study  in  this  country,  but  it  is  quite  prob- 
al)]e  that  the  John  Hunter  or  Josej)h  Lister  of  America  is  now  busy 
Avith  his  preliminary  work. 


144  THE  HISTORY  AND  LITERATURE  OF  SURGERY. 

A  most  imi>ortaiit  stc']>  in  the  })rogress  of  medicme  was  made  when 
physicians  and  surgeons  began  to  form  associations  and  societies  for  the 
purpose  of  mutual  improvement  and  for  the  piil)lication  of  papers  read 
befiire  them,  rather  tiian  for  guariHng  trade  interests;  and  the  trans- 
actions of  such  societies  form  a  most  vakiable  section  of  medical  litera- 
ture. The  first  of  these  societies  Avhich  was  devoted  specially  to  sur- 
gery, and  whose  jiublications  were  im])ortant,  was  the  Academic  royale 
de  chirurgie,  the  memoirs  of  which  appeared  in  o  quarto  volumes  (Paris, 
174.3-74,  and  again  in  15  vols.  12mo,  Paris,  1771-87,  in  5  vols.  8vo, 
Paris,   LS19,  and  in  3  vols.  8vo,  Paris,  18.38). 

The  MemoireH  and  Bulletins  of  the  Societe  de  Chirurgie  de  Paris, 
j)ublished  from  1847  to  the  present  time,  and  forming  -52  volumes;  the 
VerhcnuUunr/cn  of  the  Deutsche  Gcsellschaft  fiir  Chirurgie,  in  35  vol- 
umes, 1872-93  ;  tlie  TranKoetions  of  the  American  Surgical  Association, 
in  10  volumes,  188.3-92;  and  the  Proccs-nrboiix,  mcmoirefi,  etc.  of  the 
Oingres  fraacais  de  Cliirurgie, — are  the  most  important  of  the  purely 
sui'gical  publications  of  this  class  in  the  present  century.  No  surgical 
association  ])ublishing  professional  reports  has  existed  in  Great  Britain, 
the  Royal  Colleges  of  Surgeons  of  Edinbui-gh,  of  England,  and  in  Ire- 
land not  having  undei'taken  this  line  of  work. 

The  following  is  a  list  of  the  most  imjioi-tant  journals  devoted 
especially  to  general  surgery,  arranged  in  order  of  date : 

Chirnrr/ischc  Bihliotliek,  von  August  Gottlieb  Richter,  1771-96,  8vo,  Gtittingen 

u.  Giitlia. 
Journal  de  Cliirurgie,  par  Pierre-Joseph  Desault,  1791—92,  8vo,  Paris. 
Blljliothck  fiir  die  Chirurgie,  Hrsg.  von  C.  J.  M.  Langenbeck,  1805-13,  8vo, 

Gtittingen. 
Neue  BiUiothek  fiir  die   Chirurgie  viid  Ophthalmologie,  Hrsg.   von    C.   J.   M. 

Langenbeck,  1815-28,  8vo,  Hannover. 
Journal  tier  Chirurgie  und  Aiigeii-IJeilkniide,  Hrsg.  von  C.  F.   Graefe  und  Ph. 

von  Walther  (quarterly),   1820-50,  8vo,   Berlin. 
Giornale  di  C hirurgia-pratica ,  compilato  dal  dott.   G.   Canella,  1825-29,   8vo, 

Trento. 
Aiuudes  de  la.  ehirnrgie  fraiiraise  et  etrangere,  publiees  par  MM.   Begin,  Mar- 

chal,  Velpeau  et  Vidak  1841-45,  8vo,  Paris. 
Journal  de  Chirurgie,  par  M.  !Malgaigne,  1843-46,  Bvo,  Paris. 
Arehiv  fiir  klinisehe   Chirurgie,  Hrsg.  von   Dr.   B.  von   Langenbeck,  red.   von 

Billroth  und  Gurlt,  1860-94,  Svo,  Berlin. 
Deutsche  Zeitsehrift  fiir   Chirurgie,   Hrsg.   von   Bardeleben   (et  al.)  ;  red.   von 

C.  Hueter  und  A.  Liicke,  1872-94,  8vo,  Leipzig. 
Centralblatt  fiir   Chirurgie,   Hr.sg.   von   L.    von   Lesser,   M.  Schede,    H.   Till- 

manns  (weekly),  1874—94,  Svo,  Leipzig. 
Revue   de    chirurgie,  r^dacteurs    en  chef,  MM.   Nicaise  et  F.  Terrier;    direc- 

teurs,  MM.  Oilier  et  Verneuil,  1881-89,  8vo,  Paris. 
Annals  of  fiurgery,  a  monthly  review  of  surgical   science  and  practice,  edited 

by  L.  S.  Pitcher  and  C.  B.  Keotley,  1885-94,  Svo,  St.  Louis. 
Archives  of  Surgery,  by  J.  Hutchinson  (quarterly),  1889-94,  Svo,  London. 


SURGICAL  PATHOLOGY,  INCLUDING  INFLAM- 
MATION AND  THE  REPAIR  OF  WOUNDS. 

Bv  W.  T.  COUNCILMAN,  M.  D. 


I.  INFLAMMATION. 

Inflammation  is  one  of  the  most  inij)oi-t;iiit  subjects  in  medicine 
and  surgery,  and  one  of  the  most  difficult  to  comprehend.  It  ha.s 
played  an  important  part  in  the  history  of  medicine,  and  most  of  the 
theories  of  disease  formerly  held  were  more  or  less  based  on  conceptions 
of  its  nature.  It  is  only  in  comparatively  recent  years,  when  patient 
observation  and  experiment  have  taken  the  place  of  theory,  that  the  true 
nature  of  inflammation  has  been  better  understood. 

^\'ere  we  to  take  up  all  the  phenomena  of  inflammation  and  stud}' 
each  process  fully,  it  would  ^practically  include  all  pathology.  So  exten- 
■sive  is  the  subject,  and  so  intimately  is  it  related  to  other  pathological 
processes,  that  it  has  recently  been  proposed  to  abolish  the  term  "  inflam- 
mation" entirely,  and  to  consider  the  various  jilienomena  under  other 
divisions  of  pathology  where  they  naturally  belong.  The  phenomena 
of  inflammation  are  closely  connected  with  the  i)athology  of  the  circula- 
tion, with  the  degeneration  and  regeneration  of  tissue,  with  the  action 
of  bacteria,  with  injuries,  etc.  Still,  it  is  well  to  have  some  one  term  to 
include  the  tissue-changes  following  an  injury,  and  we  may  define  inflam- 
mation as  the  sum  of  the  phenomena  which  take  place  in  the  tissue  as  the 
effect  of  an  injury.  The  object  of  these  various  jihenomena  is  to  over- 
come or  to  diminish  the  eifects  of  the  injury.  The  study  of  inflammatory 
processes  may  be  well  begun  with  the  changes  which  take  place  in  the 
blood-vessels,  and  in  the  connective  tissue,  which  everywhere  stands  in 
close  connection  with  these. 

It  will  be  well  to  consider  the  character  of  the  normal  coimective 
tissue  and  the  relations  which  it  has  \\ith  the  circulation.  The  con- 
nective tissue  in  the  body  serves  the  important  function  of  binding 
together  the  various  parts,  and  acts  as  a  support  to  the  blood-vessels, 
which,  with  this  tissue,  grow  into  the  various  structures  in  the  course 
of  development.  The  connective  tissue  varies  in  its  structure.  It  is 
composed  of  cells  and  of  fibres  which  differ  in  their  physical  and  chem- 
ical (lualities.  In  places  the  filn-es  are  loosely  connected  together,  as  in 
the  areolar  tissues,  and  in  places  they  are  compacted  in  close  bundles,  as 
in  the  tendon.  The  number  of  blood-vessels  in  this  tissue  varies  greatly 
in  the  different  parts  of  the  body,  the  number  standing  in  exact  relation 
to  the  importance  of  the  adjacent  epithelial  structures.  Most  of  the 
blood-vessels  in  the  connective  tissue  do  not  serve  the  purpose  of  its 

Vol.  I. — 10  ]45 


146 


SURGICAL   PA  TlKiLOG  Y. 


nutrition,  (lie  tissue  simply  serving  as  a  bed  for  their  support.  Where 
the  blood-vessels  in  the  connective  tissue  are  for  the  nutrition  of  this 
alone,  they  are  not  found  in  such  large  luunbers.  The  nutrition  of  the 
tissue  is  carried  on  by  means  of  tlie  lymph  -which  passes  through  the 
walls  of  the  vessels  and  circulates  through  the  tissue.  In  some  places 
there  are  no  definite  tracks  taken  by  the  lymph.  In  the  subcutaneous 
areolar  tissue  there  is  a  loose  meshwork  of  fibres  containing  a  variable 
number  of  cells,  and  the  tissue  is  simply  saturated  M'ith  the  fluids.  In 
other  places,  aa  in  the  cornea,  the  fibres  of  the  tissue  are  compacted  into 
a  dense  mass  containing  channels  and  spaces  in  which  the  cells  lie  and 
in  which  the  lymph  circulates.  In  still  other  plac(^s  the  nutrition  seems 
to  take  place  through  the  cells  alone.  In  the  cartilage,  for  instance,  there 
is  a  compact  intercellular  suljstance,  with  no  spaces  either  around  or  be- 
tween the  cells,  so  that  the  nutrition  of  this  tissue  is  j)robably  kept  up 
from  cell  to  cell. 

The  vascular  ])henonicna  which  take  place  in  inflammation  can  be 
directly  studied  under  the  microscope  in  a  transparent  part,  as  in  the 
web  of  the  frog's  foot  or  in  the  mesentery  (Fig.  1).     The  mesentery  of 

Fig.  1. 


Portion  of  the  mesentery  of  a  froa,  showing  normal  circulation :  a,  a,  small  arteries  just  breaking 
up  into  capillaries ;  o,  b,  small  veins ;  c,  c,  wandering  cells  (leucocytes  in  connective  tissue). 

the  frog  is  a  thin  tissue  which  is  covered  on  the  outside  by  a  single  layer 
of  flat  endothelial  cells,  beneath  wliich  is  a  layer  of  rather  firmly-inter- 
woven connective-tissue  fibres,  with  numerous  blood-vessels,  nerves,  and 
lymphatics.  The  arteries  and  veins  in  the  mesentery  are  relatively  more 
numerous  than  the  capillaries,  because  the  tissue  mainly  serves  to  support 
the  vessels  passing  from  its  root  to  the  inte.stine.   Under  the  microscope  the 


INFLAMMA  TION. 


147 


normal  circulation  can  be  studied  and  the  gradual  development  of  inflam- 
matory changes  observed.  In  the  various  sorts  of  vessels  ditferences  in 
the  character  of  the  circulation  may  be  recognized.  In  the  arteries  there 
is  an  evident  pulsating  stream.  At  each  contraction  of  the  heart  the 
blood  is  swept  along  so  rapidly  tiiat  it  is  not  possible  to  recognize  tiie 
individual  coriniscles.  In  the  diastole  tlie  stream  becomes  slower  and 
we  can  see  the  individual  corpuscles.  In  tlie  veins  the  movement  of  tiie 
blood  is  a  continuous  one,  and  is  slower  than  in  the  arteries.  In  the 
capillaries  the  movement  of  the  blood  is  slow  and  regular.  Neither  in 
the  veins  nt)r  in  the  arteries  do  the  red  blood-corpuscles  completely  fill 
the  vessel.  We  recognize  a  central  core  composed  entirely  of  masses  of 
red  blood-corpuscles,  and  between  this  and  the  wall  of  the  vessel  is  a 
colorless  zone  which  contains  no  red  blood-corpuscles,  and  in  which  here 
and  there  single  wiiite  corpuscles  roll  along.  In  the  frog's  web  it  is 
necessary  to  injure  the  tissue  either  by  chemical  or  mechanical  violence 
to  produce  inflammation,  while  the  mere  exposure  of  the  mesentery  to 
the  air  produces  sufficient  injury  to  bring  about  all  of  the  phenomena. 

Fig.  2. 


The  same  vascular  territory  as  shown  in  Fig.  1,  two  hours  after  exposure.  All  of  the  vessels  arc 
(lilatetl.  The  leucocytes  aje  more  numerous  ;  they  have  eoUectea  alonp  the  walls  of  the  vessels, 
and  in  several  places  are  passing;  ihrouph  :  at  d  diapedesis  of  the  red  corpuscles  is  shtiwn, 
and  at  e  emigration  of  leucocytes.  Tlicre  are  large  numbers  of  leucocytes  in  the  connective 
tissue. 


If  care  be  taken  in  placing  the  mesentery  beneath  the  micrf)seope  to 
pi-oduee  as  little  injury  as  possible,  all  of  tlie  phenomena  will  take  place 
so  gradually  that  the  single  steps  can  be  easily  followed.  At  first  no 
changes  at  all  are  seen  in  the  circulation.  Under  some  circumstances  the 
first  change  seen  is  a  contraction  of  the  small  arteries.  This  is  always  tem- 


148  SURGICAL  PATHOLOGY. 

porarv,  and  is  often  not  observed,  and  in  any  case  it  quickly  iijives  ])lace 
to  dilatation.  The  dilatation  of"  the  arteries  is  acconijianied  hy  a  great 
rapidity  of  circulation.  The  Mood  tiows  throut>h  all  of  the  vessels  with 
increased  speed.  P^ven  in  the  capillaries  the  tlow  is  sometimes  so  rajiid 
tliat  the  individual  corpuscles  cannot  be  seen.  Vessels  appear  which 
were  jireviously  invisible  from  their  small  size.  The  veins  take  part  in 
the  dilatation,  and  the  flow  in  them  is  also  more  rapid.  This  is  the 
stage  of  active  arterial  hypenemia.  There  is  more  blood  brought  to  the 
part  by  the  dilated  arteries ;  more  passes  through  and  is  carried  oif  by 
the  veins. 

This  condition  of  the  circulation  soon  gives  place  to  another  (Fig.  2). 
The  dilatation  of  the  blood-vessels  continues,  but  the  current  becomes 
slower.     The  circulation  in  the  dilated  capillaries  may  become  so  slow 
that  they  become  filled  with  red   blood-eorpuscles,  and  appear  as  red 
lines  running  through  the  tissue.     The  slowing  of  the  current  and  dila- 
tation of  the  vessels  are  much  more  evident  in  the  veins  than  in  the 
capillaries,  and  a  marked  change  takes  place  in  the  plasma-zone  of  the 
veins.     In  the  normal  circulation  the  white  corpuscles  are  confined  to 
this  zone,  and  they  roll  along  the  wall  in  the  clear  fluid.     These  cor- 
puscles gradually  increase  in  number,  and  the  entire  plasma-zone  of  the 
vein  becomes  filled  with  them.     Although  the  blood-current  of  the  vein 
is  slow,  the  progress  of  the  white  corpuscles  in  the  plasma-zone  does  not 
keep  pace  with  that  of  the  red  corpuscles  in  the  centre.     They  will  fre- 
quently cling  for  a  time  to  the  wall  of  the  vessel,  and  then  again  be 
swept  away  by  the  current.     Numbers  of  them  remain,  and  finally  the 
wall  of  the  vessel  becomes  lined  \\ith  them.     These  corpuscles  in  the 
j)lasma-zone  undergo  ra])id  anueboid  changes,  and  may  move  from  place 
to  place  along  the  vessel.     Some  of  them  become  apparently  fixed  to  the 
wall  of  the  vessel,  and  then  a  striking  phenomenon  takes  place.     A  small 
bud  appears  on  the  outside  of  the  vessel  opposite  the  point  at  which  a 
white  corpuscle  adheres.     This  projecting  bud  gradually  becomes  larger, 
and  at  the  same  time  that  part  of  the  corpuscle  inside  the  vessel  becomes 
smaller,    and    after   a    variable    length    of    time   the    corpuscle   passes 
entirely  through  the  wall  of  the  vessel.     This  passage  of  the  white  cor- 
puscles through  the  walls  of  the  vessels  is  spoken  of  as  emigration,  and 
when  it  once  begins  it  goes  on  witli  considerable  rapidity,  until  finally 
the  tissue  outside  of  the  blood-vessels  becomes  filled  with  these  cor- 
puscles.    They  accumulate  in  the  tissue  and  lie  in  the  meshes  between 
the  fibrils  and  in  the  lymph-spaces  (Figs.  3  and  4).     The  emigration  is 
not   always  easily  observed.     To  see  it  under  the  best  circumstances 
vigorous  frogs  should  be  selected  and  care  taken  in  spreading  the  mem- 
brane out  to  produce  as  little  injury  as  possible.     It  is  much  more  easily 
seen  in  the  vessels  of  the  bladder  than  in  those  of  the  mesentery.     The 
l)ladder  can  be  filled  with  salt  solution,  turned  out  through  the  rectum, 
and  directly  observed.     Sometimes  it  takes  more  than  an  hour  for  the 
corpuscle  to  pass  through  the  \\all  of  the  vessel.     The  white  corpuscles 
accumulate  in  the  dilated  capillaries,  but  to  a  much  greater  extent  in  the 
veins.    Both  the  red  and  the  white  corpuscles  pass  through  the  walls  of  the 
capillaries.     The  red  corpuscles  may  also  pass  through  the  walls  of  the 
veins,  but  this  is  comparatively  rare.    This  passage  of  the  red  corpuscles 
through  the  walls  of  the  vessels  is  called  diapedesis.    They  pass  through 


mFLAMMA  HON. 


149 


Diagrammatic  view  of  inflammatory  changes  in  a  small  vein :  a,  normal  circulation,  showing 
plasma-zone ;  b,  c,  d,  successive  changes,  showing  dilatation,  accumulation  of  leucocytes,  ana 
emigration. 

the  walls  of  the  capillaries  in   nuich  <iroater  numbers  than  the  white 
corpiiseles. 

Not  only  do  the  white  and  red  corpuscles  pass  through  the  walls  of 


Fig.  4. 


The  process  of  emigration,  observed  under  high  power.  The  Olood  is  supposed  to  flow  on  the  left 
of  the  line  in  the  direction  indicated  by  the  arrow.  The  tissue  is  on  the  right.  X  1000.  (After 
Thoma.) 


150  SURGICAL   PATHOLOGY. 

the  vessel,  but  the  fluid  portions  of  the  blood  also  pass  throngh.  This, 
of  course,  cannot  be  directly  observed  under  tlie  niicroscope,  Idit  we  can 
easily  see  that  the  tissue  becomes  thicker  and  inliltratcd  witli  fluid.  A 
part  of  the  fluid  is  retained  in  the  meshes  of  the  tissue,  and  a  part  passes 
directly  through  to  the  surface.  Tiiese  vascular  changes  last  for  a  con- 
sideraljle  time,  and,  if  the  mesentery  of  the  frog  has  remained  under 
observation  a  long  while  or  if  it  be  allowed  to  become  dry,  the  circula- 
tion will  tinally  cease  and  the  part  will  become  gangrenous.  If  care  be 
exercised  in  the  ])reparation  of  the  specimen  and  the  mesentery  be 
replaced  in  the  abdominal  cavity,  the  vessels  in  the  course  of  a  few  days 
will  return  to  their  normal  condition. 

These  are  the  main  vascular  phenomena  which  can  be  observed 
directly  under  the  microscope.  The  process  in  all  animals  is  the 
same.  Tlioma  has  ol)served  the  circulation  in  the  niesenteiy  in  the 
small  mammalia,  under  both  normal  and  pathological  conditions,  and 
the  same  phenomena  occur.  The  same  process  may  be  observed  in  the 
wing  of  a  bat  under  the  microscope,  but  in  this  case  it  will  be  necessary 
to  produce  some  mechanical  or  chemical  injury  to  the  tissues,  the  mere 
exj)Osure  under  the  microscope  not  being  sufficient. 

The  inflammatory  changes  in  the  circulation  may  with  advantage  be 
studied  in  the  frog's  tongue.  This  contains  more  vessels  than  the  mesen- 
tery and  is  relatively  richer  in  capillaries.  The  tongue  is  attached  to 
the  jaw  by  its  anterior  extremity,  and  it  can  readily  be  drawn  from  the 
mouth,  sjiread  out  over  a  cork  ring,  and  the  circulation  observed. 
Inflanunation  may  be  produced  by  the  application  of  dilute  croton  oil 
(1  droj)  of  croton  oil  to  40  of  olive  oil)  to  the  surface,  removing  it  in  a 
few  minutes,  otherwise  it  will  produce  coagulation  of  the  blood  in  the 
vessels  with  entire  cessation  of  the  circulation.  The  same  phenomenon 
which  is  seen  in  the  mesentery  takes  place  here.  There  is  a  period  of 
intense  active  hyperannia  which  gives  place  to  stagnation,  with  emigra- 
tion of  white  and  red  corpuscles  and  increased  transudation.  The 
tongue  becomes  swollen  from  infiltration  with  fluid  and  cells.  The 
changes  are  the  more  striking  the  more  limited  is  the  injury  to  the 
tissue.  The  croton  oil  tends  to  diffuse  all  over  the  surface,  but  a  cir- 
cumscribed inflammation  may  be  produced  by  touching  the  surface  with 
a  crystal  or  a  pointed  stick  of  nitrate  of  silver.  Various  degrees  of 
vascular  disturbance  may  be  seen,  which  is  most  intense  immediately 
around  the  eschar  which  has  been  produced  by  the  caustic,  and  which 
gradually  gives  place  to  the  normal  circulation.  The  caustic  jiroduces, 
where  it  comes  in  contact  with  the  tissue,  coagulation  of  the  blood  in 
the  vessels,  with  cessation  of  the  circulation  and  necrosis  of  the  tissue. 
The  necrotic  tissue  is  converted  into  a  brown  slough  which  is  presently 
cast  off.  Immediately  around  the  eschar  is  a  dark-red  zone.  In  this  the 
blood-vessels  are  greatly  dilated,  the  circulation  is  very  slow,  in  places 
com])leteh'  stagnant,  and  the  tissue  between  the  vessels  is  filled  witli  red 
corpuscles  which  have  passed  through  the  walls.  The  redness  immediately 
around  the  necrotic  spot  is  principally  due  to  hemorrhage  by  diapedesis. 
Even  with  the  naked  eye  it  can  be  distinguished  from  the  I'edness  due 
to  hypenemia  by  its  gi-eater  intensity  and  dittiiseness.  Outside  of  this 
comes  a  zone  in  which  the  vessels  are  dilated,  the  circulation  is  slow,  and 
numbers  of  corpuscles,  both  \vliite  and  red,   but  principally  white,  are 


INFLAMMATIOX. 


151 


passing  tliroiigli  tlie  walls  of  the  vessels  and  accumulating  in  the  tissue. 
This  zone  gradually  fades  oiF  into  one  in  which  there  is  active  arterial 
hypera^mia.  In  this  way  all  the  changes  which  gradually  develop  in  the 
mesentery  can  be  seen  taking  place  at  one  time.  Here,  as  in  the  mesen- 
terv,  it  is  evident  that  there  is  also  an  increased  exudation  of  the  fluid 
portions  of  the  blood,  because  the  tissues  become  swollen  and- oedematous. 
These  areas,  which  we  have  referred  to  as  zones,  are  not  sharply  marked, 
but  one  gradually  gives  place  to  the  other. 

The  same  process  can  be  studied  on  non-transparent  parts  by  harden- 
ing them  at  various  intervals  after  the  production  of  the  injury  and 
examining  the  sections.  Acute  inflammation  may  be^  excited  in  the  ear 
of  a  rabbit  by  ruljbing  it  with  croton  oil.  The  oil  should  be  diluted 
with  5  or  (3  parts  of  olive  oil,  otherwise  a  total  necrosis  of  the  tissue 
may  be  produced.  Almost  immediately  the  ear  becomes  actively  red. 
In  twenty-four  hours  it  is  red  and  swollen.  The  redness  is  not  always 
due  to  hyperemia.  Here  and  there  small,  irregular  red  splotches  may 
be  seen  which  are  due  to  hemorrhage  into  the  tissue.  The  swelling 
involves  the  entire  ear  even  if  the  croton  ott  was  only  applied  to  the  tip. 
On  the  inside  of  the  ear  small  vesicles  filled  with  clear  fluid  are  fre- 
quently found  (Fig.  5).     Sections  of  the  ear  after  hardening  in  various 


Fig.  6. 
b 

p    XT'-   ■•..••  -^ 


■/■■^•'^i|S«?|^'^ 


Section  of  ear  of  rabbit  thirty-six  hours  after  the  application  of  croton  oil ;  the  connective 
tissue  is  swollen  from  infiltration  with  serum,  leucocytes,  and  fibrin :  a,  epidermis  ;  6,  vesicle- 
formation  :  c,  accumulation  of  leucocytes  around  necrotic  hair-follicles ;  «,  tibriu ;  e,  muscular 
layer  ;  /,  pericliondrium  ;  g,  cartilage. 

solutions — of  which  Fleming's  solution  is  the  best — show  the  vessels 
dilated,  and  in  some  ca,ses  entirely  filled  with  white  corpuscles.  Fre- 
quently the  white  corpuscles  are  confined  to  the  inner  lining  of  the 
veins,  and  in  favorable  sections  they  may  be  caught  in  various  stages  of 
emigration.  In  the  areas  of  hemorrhage  the  congestion  is  intense,  the 
tissue  is  filled  with  red  corpuscles,  but  no  rupture  of  the  vessels  can  be 
made  out.  In  the  tissue  cvery\xhere  there  are  immen,se  numbers  of  cells 
of  the  same  appearance  as  those  within  the  vessels.  They  are  u.sually 
more  numerous  close  beneath  the  epidermis,  and  the  tissue  may  be  so 


152  SURGICAL  PATIIOLOOY. 

packed  with  tliera  that  nothing  more  can  be  seen.  They  are  not  only  in 
the  tihisiiie  beneath  the  epidermis,  but  numbers  of  tlicm  have  entered 
into  this,  lying  in  the  spaces  between  the  cells,  and  in  the  fluid  in  the 
small  vesicles  numbers  of  them  arc  seen.  Toward  the  middle  of  the 
ear,  where  the  tissue  is  looser,  the  white  corpuscles  are  less  numerous, 
and  the  meshes  of  the  tissue  are  forced  apart  by  infiltration  ^\•ith  the 
fluid  which  has  escaped  from  the  vessels  along  with  the  leucocytes.  In 
the  swollen  tissue  toward  the  root  of  the  ear,  away  from  the  area  of 
injury,  there  are  few  or  no  leucocytes.  Fibrin  in  various  amounts  may 
be  contained  in  the  tissui'. 

li'  an  injury  be  produced  in  non-vascular  parts,  the  same  changes 
Avhich  are  seen  in  the  vessels  of  the  mesentery  or  in  the  vessels  of  the 
rabbit's  ear  will  take  place  in  the  surrounding  vessels  which  provide  the 
nutrition  for  the  non-vascular  territory.  The  cornea  has  usually  been 
selected  for  the  study  of  inflammation  in  non-vascular  tissues.  If  the 
central  portion  of  the  cornea  of  a  rabbit  be  injured  by  touching  it  with 
a  stick  of  nitrate  of  silver  or  caustic  jjotash,  a  necrosis  of  the  tissues 
limited  to  an  area  not  exceeding  1  to  2  mm.  in  diameter  may  be  pro- 
duced. The  tissue  immediately  affected  by  the  caustic  becomes  white 
and  opaque ;  it  afterward  becomes  dry,  and  a  scab  is  produced  which  is 
thrown  off.  For  a  time  no  change  will  be  perceived  in  any  ])ortion  of 
the  cornea,  either  immediately  around  the  injured  tissue  or  at  a  dis- 
tance. If  a  very  thin  cornea,  as  the  frog's,  l)e  chosen  for  the  experi- 
ment, the  corneal  corpuscles  immediately  around  tlie  injury  are  more 
easily  seen  than  elsewhere,  and  this  is  doubtless  due  either  to  coagula- 
tion of  the  protoplasm  of  the  cell  or  to  changes  which  have  taken  place 
in  the  intercellular  substance.  In  the  area  of  the  eschar  there  has  been 
total  destruction  of  the  cells  and  of  the  intercellular  substance  as  well, 
but  around  this,  where  the  action  of  the  caustic  Mas  less  intense,  it  is 
probable  that  necrosis  of  the  cells  ^itli  coagulation  of  the  protoplasm 
has  been  produced  without  any  alteration  in  the  character  of  the  inter- 
cellular substance.  In  the  course  of  a  few  hours  changes  begin  to 
appear  in  the  periphery  of  the  cornea  close  to  the  sclera.  The  first 
change  which  is  appreciable  is  a  slight  cloudiness  around  the  entire 
periphery  of  the  cornea  if  the  injury  has  been  produced  exactly  in  the 
centre.  If  the  caustic  was  applied  closer  to  one  margin,  the  cloudiness 
will  begin  on  the  margin  nearest  the  injury.  The  cloudiness  rapidly 
increases,  and  extends  over  the  entire  cornea  up  to  and  around  the 
injured  portion.  At  first  the  entire  tissue  between  the  sclera  and  the  site 
of  the  injury  is  clouded,  but  the  cloudiness  gradually  becomes  more 
marked  around  the  injury,  and  the  periphery  of  the  cornea  after  three 
days  may  become  completely  clear,  ^^'hen  the  cornea  is  removed,  split 
up  into  thin  lamella,  and  examined,  it  is  found  that  the  cloudiness  is 
due  entirely  to  the  presence  of  leucocytes  in  the  lympli-spaces  of  the 
tissue.  If  the  vessels  of  the  sclera  are  examined  in  the  beginning  of 
the  cloudiness,  the  same  changes  are  found  in  them  which  were  seen  in 
the  vessels  of  the  frog's  mesentery  and   tongue. 

The  experimental  study  of  intlannnation  of  the  cornea  has  played  a 
most  important  part  in  the  develojiment  of  our  knowledge  of  inflamma- 
tion. It  formed  the  battle-ground  between  the  adherents  of  Cohnheim, 
who  believed  that  the  cells  in  an  acutely  inflamed  tissue  were  exclusively 


INFLAMMATION.  -  153 

derived  from  emigration  of  leucocytes  from  the  vessels,  and  the  adhe- 
rents of  Virchow  (iind  later  Strieker),  who  believed  that  if  emigration 
of  leucocytes  took  jjlace  at  all,  it  only  played  a  subordinate  i-ole,  and 
the  new  cells  were  derived  from  multijilication  of  the  tixed  cells  of  the 
tissue. 

The  cornea  being  a  non-vascular  organ,  it  was  first  thought  that  the 
new  cells  which  apjieared  in  it  after  inflammation  was  excited  must  be 
derived  from  the  fixed  cells.  Cobnheim  showed  tliat  the  new  cells 
do  not  first  appear  around  the  injury,  but  in  the  periphery,  and  thence 
gradually  make  their  way  to  the  centre  ;  further,  that  examination  of  the 
vessels  of  the  sclera  showed  the  same  changes  which  had  been  observed 
in  the  frog's  mesentery.  He  showed  further,  in  a  most  ingenious 
way,  that  the  cells  came  from  the  vessels.  It  was  known  that  when  car- 
mine, cinnabar,  or  any  finely-divided  solid  substance  was  injected  into 
the  circulation,  the  white  corpuscles  of  the  blood  would  take  up  the  fin-- 
eign  material.  He  injected  such  substances  into  the  abdominal  vein  of 
a  frog,  and  found  them  in  the  new  cells  of  the  inflamed  cornea.  Ac- 
cording to  the  theory  of  inflammation  develojjed  by  Cohnheim,  which 
was  accepted  without  reserve  by  his  pu])ils,  the  essential  feature  of 
inflammation  is  an  alteration  of  the  walls  of  the  blood-vessels,  in  con- 
sequence of  which  they  become  more  permeable,  and  allow  not  only  the 
fluid  parts  of  the  blood  to  pass  through  more  easily,  but  the  corpus- 
cles as  well.  The  tissue-cells  played  no  part  in  the  process,  and  not 
only  the  pus-corpuscles,  but  all  of  the  new  cells  found  in  the  inflam- 
matory area,  came  from  the  blood. 

Cohnheim  was  not  the  first  to  observe  the  emigration  of  the  leuco- 
cytes. His  observations  were  made  in  ignorance  of  the  earlier  work  on 
the  subject,  but  he  saw  the  importance  of  the  jn-ocess  and  investigated 
farther.  Cohnheim's  first  observations  on  the  cornea  were  published  in 
1867.  As  early  as  1842,  Gulliver  described  the  cells  found  in  severe 
inflammation  and  suppuration,  and  com])ared  them  to  the  white  coi'pus- 
cles.  He  seems  also  to  have  been  the  first  to  observe  an  increase  in  the 
number  of  white  corpuscles  in  the  blood  during  the  pniccss  of  inflam- 
mation. Addison  in  1845  called  attention  to  the  similarity  of  the  blood-, 
lymph-,  and  pus-corpuscles.  He  found  that  all  these  cells  had  ama?boid 
movements,  that  they  resembled  one  another  greatly,  and  thought  it 
possible  tliat  they  might  be  the  same  cells.  Quitzman,  who  reviewed  the 
article  of  Addison  in  CansUitt'n  Jnhrcshcr'tcht,  says  that  it  shows  great 
penetration  and  admirable  observation,  but  that  the  only  proof  of  the 
identity  of  the  pus-cells  and  the  leucocytes  would  be  the  observation  of 
the  actual  passage  of  the  leucocytes  through  the  walls  of  the  vessels. 
Various  other  observers  after  this  called  attention  to  the  similarity  in 
the  appearance  of  white  corpuscles  and  pus-cells,  and  in  some  of  the 
atlases  of  pathological  anatomy  pus-cells  and  white  blood-corpuscles  are 
shown  side  by  side.  A^irchow  in  numerous  publications  mentions  tin's 
similarity.  The  actual  proof  of  the  matter  was  given  by  A\'aller  in 
England  in  1849,  but  his  observations  attracted  little  attention  and  were 
soon  forgotten.  Then  the  matter  rested  until  Recklinghausen  in  1862 
showed  that  the  normal  connective  tissue  contained  cells,  similar  to  the 
leucocytes,  which  wandered  through  the  tissue  in  the  lymph-spaces. 
Although  we  know  now  that  the  leucocytes  form  the  great  mass  of  the 


^r,4  SURGICAL   PArilOLOGY. 

colls  in  the  exudation  in  an  acute  iiitlanuuation,  they  are  not  the  only 
ones  present,  and  the  essential  feature  of  inflannuation  is  not  the  lesion 
of  the  vessels. 

For  the  excitation  of  intlanimatiou  an  injury  of  the  tissue  of  some 
sort  must  be  produced,  and  the  mode  by  which  the  injury  is  produced  is 
of  little  importance.  The  injury  may  be  from  a  trauma,  and  a  lesion 
of  continuity  may  be  produced.  In  many  cases  it  is  difficult  to  show 
the  anatomical  lesit)u  which  the  injury  has  produced.  Pressure  or  trac- 
tion exerted  on  a  tissue  may  act  as  a  trauma,  and  the  extent  of  the 
injury  will  depend  upon  the  elasticity  of  the  ])art.  The  consequence  of 
jjressure  may  be  the  severance  of  the  conuectidu  Ix'twcen  certain  parts, 
or,  when  the  pressure  is  of  longer  duration,  the  nutrition  of  the  part 
may  be  aifected  and  necrosis  take  place.  Very  slight  mechanical  injury 
in  individuals  with  very  vulncralde  tissues  may  produce  evident  inflam- 
mation. In  the  case  of  the  mesentery  we  have  seen  that  even  the  lay- 
ing bare  of  a  ]iart  which  is  ordinarily  covered  may  develoj)  inflamma- 
tion. Zahn  has  shown  that  when  the  mesentery  is  fully  protected  from 
drying  and  other  injuries,  and  preserved  from  contact  with  the  bacteria 
in  the  air,  it  may  remain  exposed  for  hours  without  inflammation  tak- 
ing place.  The  chemical  injuries  are  probably  more  extensive  than  the 
traumatic.  They  may  directly  produce  a  necrosis  of  the  tissue,  with 
coagulation  of  the  cells  and  intercellular  fluid,  or  they  may  exert  an 
injurious  action  on  certain  special  cells.  The  injurious  action  of  l)acteria 
is  probably  for  the  most  part  chemical,  the  tissue  being  affected  by  the 
substances  which  they  produce.  The  action  of  some  of  the  bacteria 
on  the  tissues  is  not  inflammatory  :  they  may  exert  a  specific  action 
on  the  cells,  causing  them  to  ])r<jliferate  and  to  produce  definite  new- 
tVirmations  of  tissue.  Even  this  action  may  be  accompanied  by  in- 
flammation, for  all  such  newly-formed  tissues  are  prone  to  degeneration, 
and  the  tissue  reacts  to  the  injury  of  the.se  abnormal  products  just  as  it 
does  to  injury  of  its  normal  constituents.  Heat  and  cold  may  excite 
inflammation  if  they  are  of  sufficient  intensity  or  their  action  is  suf- 
ficiently prolonged  to  have  an  injurious  influence.  In  the  same  way,  if 
injury  be  ])roduced  by  interference  with  the  normal  blood-supply  of  any 
part,  inflannuation  is  excited  around  the  injui-ed  tissue.  Electrical  stim- 
ulation cannot  excite  inflammation  unless  it  be  of  such  a  nature  that 
the  tissue  is  directly  injured.  Foreign  bodies  only  act  as  exciters  of 
inflammations  by  the  injury  which  they  produce  in  the  tissue  around 
them.  Even  in  the  inflammations  of  internal  organs  which  are  far  re- 
moved from  the  dangers  of  traumatism  the  same  thing  is  true.  The 
injury  to  the  tissue  which  is  the  cause  of  infiannnation  may  be  due 
to  the  presence  in  the  tissues  of  chemical  substances  which  are  formed 
elsewhere  in  the  body,  and  which  exert  an  injurious  action  on  certain  of 
its  cells.  The  inflammation  ()f  the  kidney  produced  by  chrome  salts  and 
cantharidin  are  examples  of  this. 

Certain  phenomena  \\-hich  are  easily  appreciable  have  since  the  time 
of  Celsus  been  regarded  as  indicating  inflammation.  They  are  in  some 
cases  more  evident  than  in  others,  and  certain  of  them  may  be  absent  or 
predominate  over  the  rest.  They  apj>ear  in  their  most  typical  form  in 
acute  inflammations  of  the  skin.  If  we  take  for  example  the  furuncle 
or  the  infectious  infiannnation  which  develops  in  the  skin  around  the 


IXFLA  MM  A  TIOX.  155 

hair-follicle  or  glands,  we  find  at  the  height  of  the  process  that  the  in- 
flamed area  is  retlder  than  the  surronnding  skin.  It  is  warmer  to  the 
toneh,  and  if  the  temperature  be  taken  with  a  surface  tiiermometer,  it 
may  be  several  degrees  warmer  than  the  neighboring  skin.  It  is  swollen, 
appears  as  an  elevation,  and  is  painful. 

The  redness  is  due  to  the  greater  amount  t)f  blood  which  is  contained 
either  in  the  vessels  or,  in  the  form  of  hemorrhage,  in  the  tissues  of  the 
part.  The  character  of  the  redness  varies.  In  the  early  stages  of  the 
inflammation  and  at  the  periphery  it  is  a  bright  red,  almost  approaeiiing 
the  color  of  arterial  blood.  As  the  inflammation  advances,  and  in  the 
centre  of  the  furuncle,  it  changes  to  the  dark  color  of  venous  blood. 
When  the  blood  is  contained  in  the  vessels  alone,  the  redness  may  be 
made  to  disappear  tjy  pressure,  the  blood  in  the  dilated  vessels  being 
driven  out  of  them.  Tlie  redness  is  also  due  to  hcmorrhagt'  in  the  tis- 
sue. The  areas  of  hemorrhage  generally  appear  as  circumscribeil  spots, 
distinguished  from  the  hyperajmia  by  the  more  intense  color.  They  are 
easily  seen  in  the  inflamed  ear  of  the  rabbit,  and  are  most  marked  where 
the  action  of  the  injurious  agent  has  been  most  intense.  By  varying  the 
dilution  of  the  croton  oil  which  is  applied  to  the  ear  the  amount  of  the 
hemorrhage  in  the  tissue  varies,  and  is  always  greatest  when  the  less 
diluted  oil  is  used.  There  is  no  tissue  in  the  body  so  well  adajtted 
to  show  inflammatory  hypersemia  and  hemorrhage  as  the  acutely  in- 
flamed pleura.  When  this  is  stripped  off  and  held  to  the  light,  it  is 
of  a  bright-red  color,  a  beautiful  network  of  dilated  vessels  can  be  seen, 
and  between  these  the  tissue  has  a  general  diffuse  redness  due  to  injec- 
tion of  the  capillaries.  Here  and  there  in  the  tissue  can  be  seen  red 
splotches  varying  in  size  from  1  to  10  mm.  in  diameter,  which  are  due 
to  hemorrhage.  More  blood  is  brought  to  the  inflamed  part  by  the 
dilated  arteries,  and  more  flows  from  it.  This  increased  passage  of 
blood  through  the  inflamed  area  takes  place  in  spite  of  the  slowness  of 
the  circulation  in  the  dilated  veins.  In  the  early  stages  of  inflamma- 
tion, in  wliieh  tliere  is  dilatation  with  increased  rapidity  of  the  circula- 
tion, it  is  evident  that  this  must  be  the  case,  and  in  the  later  stages,  in 
which  there  may  be  almost  complete  stagnation  in  the  central  portion  of 
the  area,  in  the  periphery  there  is  an  active  circulation  in  dilated  vessels. 
Lawrence  long  ago  showed  that  there  was  a  greater  flow  of  blood  from 
an  inflamed  part  by  opening  corresponding  veins  coming  from  an  inflamed 
and  from  a  normal  part. 

There  have  been  various  theories  advanced  to  account  for  the  inflam- 
matory liyperiBmia.  After  Bernard  showed  the  effect  of  cutting  the 
sympathetic  on  the  circulation  of  the  rabbit's  ear,  the  idea  arose  that 
the  inflammatory  hyperemia  might  be  due  to  paralysis  of  the  vaso- 
motor nerves.  It' can  be  shown  that  this  is  not  the  case.  After  sec- 
tion of  the  sympathetic  the  hypenemia  develops  at  once ;  in  inflannna- 
tion  it  comes  on  slowly  and  extends  slowly.  Furtlier,  the  hyperivmia 
produced  by  section  of  the  sympathetic  never  reaches  the  intensity  of 
the  inflammatory  hypertemia.  If  the  ear  is  inflamed  after  section  of  the 
sympathetic,  an  intense  hypersemia  develops — more  intense,  as  a  rule, 
than  the  inflannnatory  hyperreniia  of  the  car  with  a  normal  nervous 
supply.  Then  the  opposite  idea  was  held,  that  the  effect  of  the  injury 
was  to  produce  a  spasmodic  contraction  of  the  arteries,  so  tiiat  there 


156  SURGICAL  PATHOLOGY. 

was  really  a  diminished  supply  of  arterial  blood  to  the  jiart  ;  tlie  hyper- 
{emia  then  was  supposed  to  be  due  to  the  entry  of  blood  into  the  intlanied 
part  from  surrtpundin<;  ])arts  by  the  eollateral  eirculatioii.  There  is 
usually  in  inflammation  a  temporary  eontraetion  of  the  arteries,  but 
this  may  be  entirely  absent,  and  it  quit^kly  gives  place  to  dilataticin.  The 
theory  of  stasis  has  also  been  used  to  account  for  the  hyperemia.  This 
theory  was  intimately  connected  with  the  humoral  patholoyy  and  was 
advocated  by  Boerhaave.  It  was  supposed  that  in  inflannnation  the 
character  of  the  blood  was  altered,  tiie  corpuscles  becoming  more  adhe- 
sive, and  in  consequence  flowed  tlu-ough  the  vessels  with  more  difficulty 
and  accumulated  in  the  inflamed  part.  These  views  with  regard  to  the 
hypersemia  of  inflammation  have  l)een  given  nj),  and  the  two  theories  at 
present  used  to  explain  it  are  that  of  Cohnheim  and  that  of  Yirchow. 
Cohnheim  explains  all  the  vascular  phenomena  of  inflammation  by  an 
alteration  of  the  walls  of  tiie  blood-vessels  produced  by  the  action  on 
them  of  the  agent  causing  the  inflannnation.  Virehow  explains  tlie 
congestion  by  an  alteration  in  the  attraction  between  the  blood  and 
the  tissues.  Cohnheim  supi)Osed  that  the  changes  in  the  vessels  were 
passive  in  character,  and  were  due  to  the  effect  of  the  injury  on  them, 
and  he  attempted  to  prove  this  in  various  ways.  He  showed  that  when 
the  blood  was  cut  off  from  the  vessels  for  varying  periods,  and  then 
again  turned  into  them,  all  the  phenomena  of  inflammation  could  be 
produced,  the  degree  depending  on  the  length  of  the  ansemic  period. 
By  cutting  off^  the  blood  from  them  he  supposed  the  nutrition  of  their 
walls  was  affected,  and  tlnis  an  injury  limited  to  the  blood-vessels  was 
produced.  He  does  not  attempt  to  deflne  the  character  of  the  altera- 
tions which  the  vessels  undergo,  and  supposed  that  there  might  be  either 
chemical  or  physical  changes  produced  in  them  which  were  so  delicate 
that  they  could  not  be  detected  by  our  metiiods  of  investigation,  and 
which  manifested  themselves  only  by  their  effects.  Almost  all  that  we 
know  about  pathological  alterations  in  blood-vessels  relates  to  the  various 
degenerations  of  their  walls.  It  is  certain  tiiat  there  can  be  no  altera- 
tion of  the  walls  of  the  blood-vessels  without  affecting  the  tissues  at 
the  same  time.  The  effects  of  the  anaimia  produced  by  shutting  off 
the  circulation  from  the  ear  will  be  felt  by  the  tissues  as  well  as  by 
the  walls  of  the  vessels,  and  the  inflammation  which  follows  will  be  due 
to  the  injury  produced  in  the  tissue.  There  is  nuich  which  is  opposed 
to  the  theory  of  Cohnheim.  The  dilatiition  of  the  vessels  extends  far 
beyond  the  area  immediately  acted  on  by  the  trauma.  Sanniel  has 
shown  that  if  the  upper  portion  of  a  rabbit's  ear  be  inflamed  Ijy  ex- 
posing it  for  a  few  minutes  to  water  of  the  temperature  of  54°  C,  an 
intense  congestion  is  produced  which  affects  not  only  the  vessels  in 
the  part  which  has  been  directly  acted  on  by  the  heat,  Init  extends  to 
the  main  artery  of  the  ear.  The  central  artery  is  dilated  in  its  entire 
course  and  pulsates  strongly.  When  tile  artery  is  cut  a  considerable  dis- 
tance below  the  inflamed  area,  more  blood  flows  from  it  than  from  the 
artery  of  the  normal  ear  at  the  same  point.  In  the  case  of  the  cornea 
it  is  dii!lcult  to  assume  that  the  action  of  the  injury  producing  the 
inflannnation  could  have  extended  to  the  vessels  of  the  sclera.  It  may 
probably  be  assumed  for  a  chemical  injury,  but  in  the  case  where  an 
inflammation  is  excited  by  passing  a  thread  through  the  centre  of  the 


INFLAMMA  TIOX.  1 57 

cornea  it  is  impossiI)le  to  suppose  that  tlie  meclianieal  trauma  enuld  have 
affected  vessels  so  remote.  If  one  hand  be  acutel}'  inflamed,  the  arteries 
on  the  inflamed  side  are  dilated  and  jjulsate  more  strongly  than  on  the 
normal  side.  In  vascular  tissues  the  inflammatory  phenomena,  the  dilata- 
tion, the  emigration,  etc.,  do  not  take  place  so  far  away  from  the  injured 
tissue  as  the  sclera  is  from  the  centre  of  the  cornea.  Only  those  vessels 
which  are  immediately  concerned  in  the  nutrition  of  the  tissue  will  be 
affected.  All  the  more  recent  work  on  the  circulation  has  renioved  the 
blood-vessels  more  and  more  from  a  passive  role  in  nutrition.  The 
increased  transudation  is  not  due  to  the  vessels  becoming  simply  more 
permeable,  but  is  due  to  active  changes  in  the  vessels  brought  about  by 
influences  acting  uj)on  them.  The  view  of  Virchow  that  the  hyper- 
aemia  is  the  result  of  an  alteration  in  tlie  attraction  l:)etween  the  blood 
and  the  tissues  is  pnjbably  more  nearly  correct  than  that  of  Cohuheim. 

The  blood-supply  of  an  organ  is  regulated  entirely  by  the  need  of  the 
organ.  An  increase  of  function  is  accompanied  by  hypersemia.  The 
hypei'temia  is  not  the  cause  of  the  increased  function,  but  it  is  demanded 
by  the  greater  needs  of  a  tissue  for  blood  when  its  functional  activity  is 
increased.  In  the  case  of  a  gland  more  blood  must  be  brought  to  the 
part,  not  only  to  nourish  the  cells  in  their  increased  activity,  but  to  sup- 
ply a  greater  amount  of  material  from  which  the  specific  substances 
secreted  can  be  drawn.  We  know  from  the  work  of  Heidenhain  that 
in  the  ordinary  jirocess  of  secretion  the  capillaries  do  not  play  a  passive 
part,  allowing  indefinitely  all  the  fluids  of  the  blood  to  pass  through, 
from  which  the  cells  may  take  uj)  certain  speciflc  elements,  but  the  cap- 
illaries themselves  may  be  regarded  as  true  secreting  structures,  and  they 
allow  only  the  substances  necessary  for  each  particular  tissue  to  pass 
through  them.  Wiien  a  portion  of  an  organ  undergoes  atrophy  or  when 
there  is  a  i)ermanent  loss  of  substance,  however  brought  aliout,  not  only 
will  tlie  su]iply  of  blood  be  diminished  by  a  reduction  of  the  calibre  of 
the  blood-vessels  brought  about  by  coutraetion  of  the  muscles,  but  it  will 
be  permanently  lessened  by  the  formation  of  a  tissue  inside  of  the 
artery  which  brings  about  a  permanent  diminution  of  its  calibre.  On 
the  other  hand,  when  a  tissue  calls  for  a  greater  amount  of  blood  than 
can  be  supplied  by  the  artery,  as  in  the  case  of  collateral  circulation 
when  one  of  a  series  of  small  arteries  takes  the  place  of  a  larger,  the 
calibre  of  the  artery  will  not  only  be  increased  by  a  relaxation  of  its 
walls,  but  it  will  be  permanently  increased;  it  will,  in  fact,  become  larger 
by  growth. 

The  hyperemia  in  inflammation  is  apparently  called  forth  by  the 
needs  of  the  tissue  for  repairing,  and  for  in  other  ways  setting  aside 
the  consequences  of  the   injury. 

The  temperature  of  the  inflamed  part  is  increased.  It  is  due  solely 
to  the  fact  that  more  heat  is  br juglit  to  the  part  by  the  increased  afflux 
of  arterial  blood,  and  the  rapitlity  of  the  circulation  does  not  allow  suf- 
ficient time  for  its  dissipation.  When  active  hypersemia  is  produced  in 
the  rabbit's  ear  by  section  of  the  symjjathetic,  it  can  easily  be  sho\vn 
by  folding  the  ear  over  an  ordinary  thermometer  that  the  temperature 
of  the  inflamed  car  is  four  or  five  degrees  above  that  of  the  normal. 
The  first  exact  experiments  with  regard  to  the  temperature  in  inflamed 
parts  were  made  by  John  Hunter.     Hunter  showed  tiiat  the  fluid  con- 


158  SUBGICAL  PATHOLOGY. 

tained  in  a  hydrocele  liad  a  temperature  when  it  was  tapped  of  .'53.3° 
C,  and  on  the  next  day,  after  actual  intlaniniation  had  taken  ])lace, 
the  introduction  of  a  thermometer  into  the  sac  showed  a  temperature 
of  37.8°.      He  showed  further  that  when  an  acute  inflammation  w^as 
produced  in  internal  parts,  as  in  the  pleura,  the  peritoneum,  the  peri- 
cardium, or  the  deep  muscles  in  the  back  and  legs,  the  tem])eratnr(>  of 
the  inflamed  part  not  only  did   not  exceed,  but  it  freipiently  did  not 
reach,  the  normal  temjjcrature  at  the  same  place.     As  a  result  of  his 
experiments  Hunter  taught  that  in   local    inflammation   the  tempera- 
ture does  not  exceed  that  of  the  interior  of  the  body.     The  correctness 
of  Hunter's  conclusion  was  ojiposcd  later  l)y  Simf)n  and  Weber,  who 
found  in  peripheral  inflaniinations  produced  l)y  fracture  of  bones  or  by 
the  injection  of  croton  oil  into  an  extremity  that  the  temperature  of 
the   inflamed   part  was  greater  than   that   of  the   blood  in  the  artery 
going  to  the  part.     This  was  in  accord  with  the  theory  of  Zimmerman 
which  afterward  appeared.     It  is  known  that  a  general  systemic  affection 
in  which  the  temperature  of  the  entire  body  is  increased  frequently 
accompanies  a  local  inflammation.    This  is  the  inflammatory  or  traumatic 
fever.     Zimmerman  advanced  t\w  theory  that  the  inflamed  ])art  repre- 
sented a  local  production  of  heat  which  led  to  increased  temjierature  in 
the  entire  body,  the  increased  tem]icrature  of  the  body  being  due  to  the 
heating  of  the  blood  in  the  inflamed  part.     A  repetition  of  all  of  these 
experiments  \\'ith   more  exact  methods  of  measuring  the   temperature 
bv  the  use  of  the  thermopyle  and  the  galvanometer,  which  were  carried 
out  by  Jacobson  and  his  scholars,  showed  that  the  temperature  of  the 
rabbit's  ear  in  the  course  of  inflammation  produced   by  croton  oil  is 
higher  than  that  of  the  normal  ear,  but  considerably  lower  than  that 
of  the  rectum  or  vagina  of  the  animal ;  and  further,  that  in  inflamma- 
tion of  the  deep  muscles  of  the  leg  there  is  very  slight   or  even  no 
increase  of  temperature  over  that  of  the  sound  leg.     In  acute  jsleurisy 
and  peritonitis  the  temperature  of  the  inflamed  cavity  is  the  same  as, 
or  sometimes  less  than,  that  of  the  blood  inside  of  the  heart.     The 
degree  of  heat  in  the  inflamed  part  will  difl'er  materially  according  to  the 
character  of  the  inflammation.    In  the  early  stages  of  inflammation,  when 
there  is  an  active  arterial  hyperiemia,  the  temperature  will  be  greater 
than  in  the  later  stages,  when  the  active  hyperannia  has  given  place  to 
stagnation.     Also,  in  an  intense  inflammation  ju-oduced  in  the  rabljit's 
ear,  in  which  there  is  stagnation  and  a  great  deal  of  hemon-hage  in  the 
tissue,  the  temperature,  instead  of  being  greater,  may  be  considerably  less 
than  that  of  the  opposite  ear.     In  any  experiments  with  regard  to  tem- 
perature in  inflammation  the  temperature  of  the  inflamed   part   must 
always  be  compared  M'ith  the  temperature  of  the  interior  of  the  body  of 
the  same  animal.     A  considerable  amount  of  fever  may  be  produced  by 
even  a  comparatively  slight  degree  of  inflanunation,  and  if  the  tenijiera- 
ture  of  the  inflamed  part  were  simply  compared  with  that  of  the  usual 
normal  temjierature  of  the  animal,  erroneous  conclusions  might  be  drawn. 
Pain  in  inflammation  is  due  to  the  distention  of  the  part  and  the 
]iressure  which  is  produced  on  the  nerves,  or  by  the  direct  action  of  the 
inflammatory  cause  on  the  nerves.     The  character  of  the  pain  will  differ 
in  different  tissues  of  the  body  and  in  the  various  sorts  of  inflammation. 
In  very  acute  inflammations,  when  the  swelling  has  taken  place  rapidly, 


INFLAMMATION.  159 

the  pain  frequently  lias  a  marked  pulsiiting  eliaracter,  because  every 
addition  of  blood  which  is  bi'ougiit  to  the  part  by  the  systole  of  the  heart 
will  temporarily  increase  the  pressure  on  the  nerves,  and  consequently 
the  pain.  It  is  evident  that  the  pain  in  tissues  poorly  supplied  with 
nerves  will  be  less  severe  than  in  parts  which  are  extremely  sensitive. 
The  anatomical  character  of  a  tissue  will  also  have  an  influence  on  the 
degree  and  character  of  the  pain,  which  may  be  entirely  disproportionate 
to  the  abundanc^e  of  nerves.  In  inflammation  of  dense  fibi'ous  tissues, 
which  are  incapable  of  much  distention,  greater  pressure  and  injury  of 
nerves  are  brought  altout  than  in  a  part  where  the  tissues  are  more  lax. 
Inflammations  of  the  periosteum  or  of  the  fibrous  tissues  about  joints  are 
intensely  painful.  Not  only  do  these  local  conditions  iufluence  the 
degree  and  the  character  of  the  pain,  but  general  conditions  of  the  body 
may  also  exert  an  influence.  A  condition  of  hypcraisthesia  may  be 
brought  about  either  by  local  changes  in  the  nerves  of  the  inflamed  part 
or  by  the  efl'cct  of  fever  on  the  nervous  centres. 

The  swelling  of  the  inflametl  part  is  due  to  an  increase  of  material  in 
the  part.    There  is  utit  only  an  increased  amount  of  fluid  in  the  inflamed 
part,  but  the  cellular  elements  are  also  increased.     The  volume  of  a  part 
in  the  state  of  inflammation  is  also  slightly  increased  by  the  increased 
amount  of  blood  in  the  vessels,  but  this  has  so  slight  an  influence  that 
it  may  l)e  left  out  of  consideration.     We   know  that  hyperemia  will 
produce  an  increase  of  volume.     The  fluid  which  is  present  in  the  in- 
flanuuatory  tumor   comes    from  the  blood-vessels ;   the  transudation  is 
increased.     Not  only  does  the  fluid  accumulate  in  the  tissues  in  this  way, 
but  there  is  an  increased  flow  in  the  lymphatics  going  from  the  part. 
Cohnheim  showed  that  when  a  canula  is  placed  in  a  main  lymphatic  of 
the  leg  after  an  acute  inflaunnation  has  been  produced  in  the  foot  by  the 
action  of  crotou  oil  or  hot  water,  tiiere  is  a  greatly  increased  flow  of  lym})h 
as  compared  with   the  other  side.     On  dissecting  out   the   lym])iiatics 
coming  from  an  inflamed  part  they  are  found  full  and  turgid.     Chemical 
analysis  of  the  lymph  in  inflammation  has  shown  that  it  is  much  more 
concentrated  than  the  normal  lymph.    A  solid  residue  of  6  or  7  per  cent, 
has  frequently  been  foimd  in  the  inflammatory  exudation  in  man,  and 
Lasser  has  shown  that  tin-  lymph  from  the  inflamed  foot  contains  6|  to 
8  per  cent,  of  solid  constituents.    The  salts  are  not  increased.    All  inves- 
tigators are  agreed  that  they  are  found  in  almost  the  same  proportions  in 
the  inflammatory  transudations  as  in  the  normal  lymph.     The  increased 
concentration    depends    entirely  upon  an    increase    in    the   amount   of 
albumin.     Tliere  is  a  mai-ked  ditf'crcnco  lietwcen  the  character  of  the 
cedematous  fluid  in  inflanuuation  as  compared  with  tliat  of  tiic  ordinary 
dropsy  from  chronic  passive  <'ougestiou.     The  dropsical  accumulations 
contain  but  little  albumin,  and  the  normal  lympii  has  an  intermediate 
relation   between  the  two  in  the    projiortion  of  albumin.     In  inflam- 
matoiy    lym])h    there    is   a   greater   tendency   to   coagulation    than    in 
normal  lympii.     Dropsical  accumulations   either   do    not    coagulate  at 
all  or  very  slowly,  and  a  soft  clot  is  produced.     Lasser  found  ditticulty 
in  obtaining  lymph  from  the  lymphatics  of  an  inflamed  part  on  account 
of  its  great  tendency  to  coagulation,  the  canula  becoming  in  a  short  time 
filled  with  the  clot.     The  increased  coagulability  of  the  lymph  is  due  in 
great  part  to  the  increased  number  of  colorless  corpuscles. 


160  SVIiaiCAL    I'ATIKJLOGV. 

Cohnheim  regards  this  altcratidii  in  the  character  of  the  transiulation 
as  due  entirely  to  alterations  in  tiie  walls  of  the  blood-vessels.  The 
character  of  the  filtrate  is  altered,  because  the  character  of  the  tilter,  the 
wall  of  the  blood-vessel,  is  altered.  He  rightly  supposed  that  the 
increased  transudation  in  inflammation  is  not  due  to  a  simple  increase  of 
jircssure  within  the  vessels,  because  the  character  of  the  fluid  is  difl'erent 
from  that  in  chronic  passive  congestion,  which  is  due  to  such  increase. 
It  is  impossible  to  compare  exactly  the  character  of  the  transudation 
in  the  two  cases  by  observation  of  the  fluid  in  the  lympiiatic  vessels. 
In  chronic  passive  congestion  the  lymph  as  it  escapes  from  the  vessels 
comes  in  contact  ^vith  a  tissue  which  is  unaltei'ed.  In  inflammation  the 
lymph  comes  in  contact  w'ith  abnormal  tissues.  In  the  tissue  of  the  jiart 
in  which  there  is  inflammation  there  are  various  changes  taking  place, 
^•arious  degenerations  have  been  produced  by  the  injury  which  has  caused 
the  inflammation,  and  all  of  these  factors  may  exert  an  influence  on  the 
character  of  lymph  flowing  through  it.  It  is  probably  true  that  in  in- 
flammation the  character  of  the  transudation  passing  through  the  vessel- 
walls  is  diflei'ent  from  the  normal,  and  difl'erent  from  that  in  chronic 
passive  congestion.  But  its  character  is  not  due  to  changes  which  have 
taken  place  in  the  walls  of  the  blood-vessels,  in  consequence  of  which 
they  f)assively  allow  a  ditt'erent  fluid  to  pass  through  them,  l)ut  the 
vessels  actively  secrete  a  difl'erent  fluid.  The  character  of  the  transuda- 
tion may  difier  also  in  the  various  sorts  of  inflammation.  A  difl'erent 
fluid  is  needed  by  the  tissues,  and  there  will  be  a  diiference  in  the  tran- 
sudation, just  as  there  is  a  difl'erent  lymph  secreted  by  the  blood-vessels 
of  the  kidney  as  compared  with  that  secreted  by  the  blood-vessels  of  the 
pancreas.  This  increased  flow  of  lym])h  in  inflammation  has  a  ])urpose- 
ful  character  independent  of  afl'ording  a  greater  degree  of  nutriment  to 
the  tissues.  By  it  soluble  chemical  substances — substances  either  pro- 
ducing the  inflammation  of  the  tissue  in  the  first  place  or  substances 
which  are  produced  in  the  inflamed  area  by  the  action  of  bacteria  which 
may  be  there — are  diluted  or  washed  away. 

In  the  inflamed  part  the  lymph  will  accumulate  in  the  interstices 
of  the  tissue,  in  the  lymjjhatic  vessels  and  lymph-spaces,  and  give  rise 
to  oedema  of  the  part.  By  pressure  it  may  be  pushed  from  one  place 
into  another,  just  as  by  pressure  the  blood  can  be  removed  from  the  ves- 
sels of  a  part.  A  deep  dei)ression  or  pit  remains  at  the  seat  of  pressure, 
which  w'ill  disappear  when  the  fluid  returns.  There  may  be  inflam- 
mations in  which  the  swelling  is  due  entirely  or  almost  entirely  to  the 
increased  fluid  transudations.  Such  inflanmiations  may  be  spoken  of  as 
cedematous  inflammations,  and  they  generally  represent  a  milder  degree 
of  inflammation.  One  of  the  most  marked  examples  of  a  simple  cedema- 
tous inflammation  is  that  produced  by  the  action  of  the  sun.  We  may 
have  here  a  very  mild  degree  of  inflammation  in  which  there  is  only 
hypersiemia  with  increased  fluid  transudation. 

Samuel,  in  his  work  on  inflanunation,  has  very  properly  separated  the 
cedema  in  an  inflamed  part  due  to  the  inflammatory  cause  from  the 
a?dema  in  adjacent  parts  which  frequently  supervenes  on  inflammation. 
Thus,  when  the  extremity  of  a  rabbit's  ear  is  inflamed  there  will  be 
cedema  not  only  in  the  inflamed  portion  of  the  ear,  but  also  lower  down 
in  the  ear,  where  no  injury  of  the  tissue  has  been  produced.      This 


INFLAMMATION.  161 

Samuel  distinguishes  as  inflammatory  oedema  in  contradistinction  to  the 
cedematous  inflammation.  It  is  due  merely  to  an  extension  of  the  a?dema 
from  the  inflametl  territory,  and  is  sometimes  spoken  of  as  collateral 
cedema.  The  same  thing  can  be  seen  in  tiic  sulicntaneous  (edema  of  the 
chest-walls  which  sometimes  accompanies  inflammation  of  the  pleura. 
This  oedema  was  also  studied  fully  by  John  Hunter,  who  speaks  of  it  as 
being  s([ueezed  from  the  inflamed  part  into  adjacent  parts. 

The  tumor  contains,  in  addition  to  tlie  fluid,  a  certain  portion  of  solid 
material.  In  the  first  place,  it  contains  a  varial)le  amount  of  fibrin. 
Not  only  is  the  lymph  which  passes  from  the  inflamed  part  richer  in 
fibrin  than  the  normal  lymph,  but  in  many  inflammations  tliere  is 
formation  of  fibrin,  a  certain  amount  of  coagulation,  in  the  inflamed 
part  itself  In  the  inflannnatory  exudation  all  the  necessary  elements 
for  the  formation  of  fibrin  are  present.  P^ibrin  is  due  to  the  action  of 
a  ferment,  usually  spoken  of  as  the  fibrin-ferment,  on  certain  substances 
in  the  blood.  This  fibrin-ferment,  there  is  every  reason  to  believe,  is 
formed  from  the  disintegration  of  cells.  In  the  ordinary  process  of 
coagulation  it  is  probable  that  the  leucocytes  of  the  blood  form  the 
source  of  the  ferment,  l)ut  it  may  be  ]iroduced  by  the  disintegration  of 
the  cells  of  the  tissue.  In  the  inflamed  part  there  is  an  abundance  of 
fibrinogen  in  the  exudation,  and  tlie  fibrin-ferment  is  produced  by  the 
disintegration  of  cells.  Fibrin  is  present  in  almost  any  acute  inflam- 
mation. On  examination  of  the  inflamed  car  of  the  rabbit  after  suit- 
able hardening  a  varying  amount  of  fibrin  is  found  in  the  exudation, 
the  amount  depending  largely  on  the  intensity  of  the  inflammation.  In 
some  (;ases  there  are  only  a  few  fibrillte  scattei'ed  through  the  tissue,  and 
in  other  cases  there  are  large  masses  of  it.  In  many  cases  the  fibrin 
may  be  seen  radiating  out  from  the  ni'crotic  cells.  The  hardness  of  the 
inflamed  part,  especially  the  so-called  brawny  induration  which  is  found 
in  certain  sorts  of  inflammation,  is  due  to  the  presence  of  fibrin.  In 
certain  forms  of  inflammation  the  fibrin  may  be  present  in  excessive 
amounts. 

In  any  inflamed  part  in  which  there  is  an  increased  number  of  cells 
in  the  tissues  a  certain  number  of  red  cor})uscles  will  nearly  always  be 
found.  With  regard  to  these  we  know  that  they  could  only  come  from 
the  blood-vessels,  and  they  are  found  in  vai'ving  numbers,  dependent  on 
the  character  and  intensity  of  the  inflammation.  In  some  cases  they  are 
present  in  such  excessive  numbers  that  the  inflammation  is  spoken  of  as 
hemorrhagic.  These  corpuscles  escape  into  the  tissues  from  tlie  capillary 
vessels,  and  can  easily  be  seen  to  pass  tlu'ougli  tlie  M'alls  of  these  vessels 
when  the  inflammation  is  directly  observed  under  the  microscope. 

A  large  jiroportion  of  the  cells — and  in  some  inflammations  nearly 
all — are  white  corpuscles  which  have  emigrated  from  the  vessels.  With 
the  increased  knowledge  of  the  corpuscles  of  the  blood  which  has  come 
from  its  more  careful  study  in  recent  years  we  know  that  the  white  cor- 
puscles ditt'cr  materially  fr(im  one  another  in  form,  and  that  they  have 
difl'erent  values  and  diflerent  origins.  Tlie  most  numerous  corpuscles 
are  tlie  so-called  polynuclear  leucocytes.  These  form  between  80 
and  85  per  cent,  of  the  entire  number  of  leucocytes,  and  are  cha- 
racterized by  an  irregular  nucleus.  This  nucleus  stains  brightly,  and, 
although  spoken  of  as  a  multiple  nucleus,  it  is  in  most  cases  a  single 

Vol.  I.— 11 


162  SURGICAL  PATHOLOGY. 

nucleus  divided  into  several  masses  wliieli  are  connected  together  by  fine 
tilaments.  These  corpuscles  also  differ  from  one  another  in  the  chem- 
ical composition  of  their  protoplasm.  This  is  shown  by  their  reaction 
to  staining  agents.  In  the  great  majority  of  them  the  protoplasm  con- 
tains very  fine  granules  which  are  stained  with  the  neutral  or  basic 
aniline  colors.  In  a  certain  proportion  of  them  the  granules  in  the  pro- 
toplasm are  larger  and  stain  brightly  with  eosin.  Next  to  these  in 
number  and  importiuice  are  the  so-i:alled  leucocytes  of  the  blood.  In 
these  two  sorts  can  be  distinguished.  The  most  numerous  arc  corpuscles 
which  are  about  the  size  of  the  cells  contained  in  the  lymph-glands,  and 
which  have  a  large  round  nucleus,  and  a  very  small  amount  of  proto- 
plasm around  this.  There  are  a  certain  number  of  larger  cells  of  the 
same  character.  Although  other  cells  have  been  described  in  the  blood, 
these  are  the  only  ones  which  need  concern  us  in  the  study  of  inflamma- 
tion. In  the  corpuscles  first  described  the  nucleus  frequently  takes  the 
shape  of  a  horseshoe. 

The  polynuclear  leucocytes  are  the  most  numerous  of  the  cells  found 
in  the  swollen  tissue  in  acute  inflammation.  In  some  cases  they  are  ap- 
parently the  only  new  cells  found  iu  the  tissue.  In  the  inflamed  cornea 
in  the  early  stages  of  inflanmiation  the  cells  found  in  the  lymph-spaces 
are  exclusively  those.  There  have  been  many  theories  advanced  to 
explain  how  these  cells  pass  through  the  walls  of  the  vessels.  The  first 
idea  held  by  Cohnheim  was  that  the  passage  was  effected  by  means  of 
their  amoeboid  movements — that  they  crawled  through  the  walls.  The 
corpuscles  when  adhering  to  the  walls  before  the  emigration  has  begun 
show  active  amceboid  movements,  and  when  in  the  act  of  passing 
through,  both  the  part  outside  of  tlie  vessels  and  that  inside  show  active 
amceboid  motion.  Cohnheim  afterward  gave  up  this  idea,  and  con- 
sidered that  the  white  corpuscles,  like  the  red,  did  not  pass  through  by 
means  of  their  own  activity,  but  l\v  passive  filtration.  He  was  chiefly 
led  to  this  view  from  the  fact  that  when  the  blood-current  ceased  in  the 
dilated  veins  the  process  of  emigration  ceased.  There  may  be  another 
explanation  of  this.  The  leucocytes  are  probably  kept  against  the  wall 
of  the  vessel  by  means  of  the  blood-current,  and  probably  by  the  con- 
tinuance of  the  circulation  they  are  excited  to  moi'e  active  amoeboid 
movements.  Their  collection  in  the  vessels  of  the  inflamed  part  is 
partly  due  to  the  slowness  of  the  circulation,  but  more  to  a  voluntary 
action  on  their  part.  The  inflamed  tissue  exerts  an  attraction  for  them. 
Substances  which  have  the  power  of  stopping  the  amceboid  movements 
of  the  corpuscles  also  stop  the  emigration.  Thoma  has  shown  that 
when  salt  solution  of  the  strength  of  1  :  12  is  injected  into  the  blood 
the  amoeboid  movements  of  the  leucocytes  cease,  and  the  process  of  emi- 
gration ceases  in  inflammation.  If  the  frog  is  completely  chloroformed, 
the  action  of  the  chloroform  may  extend  to  the  leucocytes  and  stop  any 
amceboid  movements,  and  emigration  will  not  take  place.  Cohnheim 
supposed  that  the  filtration  of  the  corpuscles  through  the  vessels  was 
due  to  an  alteration  in  the  vessel's  wall,  together  with  the  increased 
pressure.  He  did  not  attempt  to  define  the  character  of  this  alteration, 
Ijut  supposed  it  might  be  physical  or  chemical.  The  most  accurate 
observations  on  this  subject  seem  to  show  that  the  leucocytes  pass 
between  the  endothelial  cells  of  the  vessels.     There  are  small  openings 


IXFLAMMATIOX.  163 

between  these  cells  in  the  normal  condition  of  the  vessel,  and  these 
V)jienini;s  prol)ably  become  laraer  when  the  vessel  is  dilated.  lionciiard 
thinks  tiiat  the  endothelial  cells  in  the  vessels  may  contract  and  assnnie 
a  round  form,  leaving  large  openings  between  them  through  which  the 
corpuscles  pass.  The  emigration  of  the  leucocytes  is  due  to  active 
amoeboid  movements  on  their  part,  possibly  assisted  by  a  more  porous 
condition  of  the  walls  of  the  vessel. 

It  is  known  that  eheniii'al  substances  liave  the  power  of  attracting  or 
rc])elling  cells  capable  of  indciiendcnt  motion.  This  \vas  shown  first  by 
Engelman  in  certain  of  the  myxomycetes.  It  is  seen  in  a  marked 
degree  in  bacteria.  The  phenomenon  was  carefully  observed  in  the 
leucocytes  bv  Gabrischweisky.  He  found  that  when  capillar}-  tubes 
were  partly  filled  with  certain  substances  and  placed  in  the  tissues  of 
animals,  the  tubes  became  filled  up  with  leucocytes.  When  they  were 
filled  witii  indifferent  substances,  only  a  small  number  of  leucocytes 
entered  into  them,  and  other  substances  exerted  a  repellant  action. 
Necrotic  tissue  of  all  sorts  attracts  tiie  leucocytes  to  it.  No  better 
proof  can  be  given  of  this  than  the  collection  of  leucocytes  around  a 
lesion  in  the  centre  of  the  cornea.  Althougli  they  pass  from  the  vessels 
of  tiie  sclera,  tliey  do  not  wander  into  the  tissue  at  random,  but  march 
directly  to  tlie  inflamed  focus.  Wiiat  the  nature  of  the  chemical 
substance  is  which  exerts  tiiis  attraction  for  the  leucocytes  we  do  not 
know.  It  is  jjroduced  in  necrotic  tissue  everywhere.  Although  most 
of  the  bacteria  have  a  decided  action  in  attracting  leucocytes,  this  attrac- 
tion is  more  strongly  exerted  when  they  are  dead  than  when  they  are 
living.  It  is  prol)able  tliat  substances  are  produced  in  the  necrotic 
tissues  whicli  by  diffusion  extend  tiieir  action  to  the  vessels,  producing 
in  these  the  inflammatory  phenomena.  Not  only  is  the  influence  felt 
on  tiie  vessels,  but  it  extends  to  the  cells  within  them,  causing  these  to 
pass  through  the  walls  and  to  accumulate  around  tiie  necrotic  tissue. 

Tiie  cells  in  some  inflammations,  ami  in  tlie  early  stages  of  all,  are 
composed  entirely  of  tliese  polynuclear  leucocytes.  Along  with  them  in 
other  cases  cells  similar  to  the  lympliocytcs  in  the  blood  appear. 
Usually  they  appear  somewhat  later  than  the  polynuclear  leucocytes, 
and  in  inflammations  of  a  less  active  chai-acter.  They  are  principally 
formed  in  the  outermost  zone  of  the  inflammatory  area,  and  usually  are 
seen  in  small  groujjs  around  the  vessels.  There  is  mucli  dispute  about 
their  origin.  While  all  observers  are  agi'eed  that  tlie  polynuclear  leuco- 
cytes come  from  tlie  blood,  it  is  held  by  some  that  the  small  lymphocytes 
have  the  same  origin.  Others  iiold  tliat  they  are  formed  by  prolifera- 
tion of  the  tissue-cells.  Baumgarten  especially  holds  the  former  view. 
His  studies  of  the  cells  in  inflammation  were  «iade  on  the  histogenesis 
of  tubercle.  Tlie  round  ]ym])liocytes  enter  largely  into  the  structure  of 
this,  and  lie  believed  tliat  they  come  from  the  l)lood  and  enter  into  the 
tubercle,  which  is  at  first  formed  of  large  cells  derived  from  the  tissue. 
Ribbert  and  Marchand  also  believe  that  these  cells  arc  leucocytes.  In 
the  more  chronic  inflammations  the  new  cells  may  be  almost  exclusively 
of  this  character.  There  are  many  objections  to  these  views.  Although 
we  are  not  able  to  study  the  course  of  inflammation  so  thoroughly  in 
man  aii<l  the  iiiammalia  as  in  the  frog,  still  by  the  modern  methods  of 
histological  technique  we  are  able  to  study  the  process  which  is  going  ou 


164  SURGICAL  PATHOLOGY. 

in  any  one  stage  of  inflammation.  As  far  as  I  have  been  able  to 
observe  the  process  of  acute  infiannnation  in  man  by  means  of  thin 
sections  of  tissue  carefully  hardened,  the  jjolynnclear  leucocytes  are  the 
only  ones  which  ])ass  throuifli  the  vessels.  In  acute  iuflainniation  of  the 
skin  the  vessels  of  tJie  papiihe  are  closely  packed  witli  these  cells,  and 
they  may  be  observed  in  every  stage  of  passage. 

The  origin  of  the  cells  in  the  inflamed  territory  has  been  a  subject 
of  dispute  in  pathology.  C'ohnhein  at  first  believed  that  all  the  new 
cells  were  leucocytes,  but  he  afterward  modified  his  views,  and  admitted 
that  in  the  later  stages  of  inflammation  regenerative  plienomcna  took 
place  in  the  surrounding  tissue-cells,  leading  to  the  fDrniation  of  new 
cells.  The  new  cells  so  formed  were  distinguished  from  the  inflamma- 
tory cells,  and  were  destined  to  renew  the  tissue  which  had  been  de- 
stroyed. Cohnheim's  view  was  directly  opposed  to  that  of  Virchow. 
According  to  Yirchow,  the  essential  condition  in  inflammation  is  an 
altered  nutrition  of  the  tissue.  In  consequence  of  the  injury — or,  as  he 
calls  it,  the  irritant— the  cells  of  the  tissue  \\erc  \-ariously  aifected. 
They  were  roused  to  an  increased  activity  which  might  be  simply  mitri- 
tive  or  formative.  They  niiglit  increase  in  size,  with  an  increase  of  their 
functional  activity,  or  they  might  multiply.  All  of  the  vascular  phe- 
nomena he  considered  to  l)e  secondary  to  this  altered  nutrition  of  the 
tissues,  and  due  to  this.  Virchow  was  one  of  the  earliest  authors  to 
recognize  the  similarity  of  the  new  cells  in  inflammation  to  leucocytes, 
but  he  supposed,  in  spite  of  the  similarit}',  that  they  were  formed  by 
multiplication  of  the  cells  of  the  tissue.  Vii'chow's  views  underwent 
some  modification  at  the  hands  of  Strieker.  While  Strieker  does  not 
deny  the  emigration  of  the  leucocytes,  he  thinks  that  these  form  but  a 
small  part  of  the  cells  which  are  formed  in  the  inflannnatory  exudation. 
He  accepts  the  view  of  Virchow  that  most  of  the  cells  are  derived  from 
proliferation  of  the  cells  of  the  tissue,  and  he  compares  the  cell  under 
its  ordinary  conditions  to  a  bent  bow.  He  holds  that  they  have  a  certain 
amount  t)f  stored-up  formative  energy,  which  under  the  influence  of  the 
inflannnatory  irritant  can  be  expended  in  a  new  formation  of  cells,  the 
inflammatory  irritant  acting  as  the  unloosing  of  the  arrow.  Afterward 
he  still  furtlier  modified  tiiis  view,  holding  that  not  only  do  the  cells  of 
the  tissue  proliferate,  but  new  cells  are  formed  from  the  intercellular 
tissue.  This  view,  first  given  by  Strieker,  that  a  new  formation  of  cells 
can  take  place  from  the  intercellular  substance,  has  been  taken  up  by 
Grawitz.  According  to  Grawitz,  in  the  development  of  the  tissue  only 
a  certain  number  of  cells  are  nsi'd  uji  in  the  formation  of  intercellular 
substance.  Many  of  them,  without  losing  their  character  as  cells,  be- 
come invisible  and  apparently  form  a  part  of  the  intercellular  substance. 
Under  the  influence  of  the  inflannnatory  stimulant  these  cells,  which 
Grawitz  speaks  of  as  the  slumliering  cells,  become  visible,  multiply, 
and  form  a  large  part  of  the  cells  in  the  inflammatory  tumor.  Cohn- 
heim  \vas  led  to  alter  his  former  views  as  to  the  exclusive  ])resence  of 
leucocytes  in  the  inflammatory  tumor  by  the  work  done  in  his  labor- 
atory i)y  Senftleben.  Various  oltservcrs  had  described  changes  in  the 
corneal  corpuscles  during  inflammation.  Virchow  had  described  swell- 
ing and  nuiltijflication  of  cells  in  the  periphery,  and  considered  that  the 
cloudiness  of  the  tissue  was  due  to  such  changes  in  the  cells.     Multipli- 


INFLAMMATION.  165 

cation  of  the  cells  was  described  by  His  and  numerons  otiier  anthors, 
and  Axel  Key  described  changes  in  the  cells  immediately  aronnd  tiie 
inflamed  area.  Most  of  tiiese  eiiang-es  described  in  the  cells  were 
cither  falsely  interpreted  as  cell-nniltiplieatiDn  or  tliey  were  degen- 
erative phenomena.  Senftlcben  was  the  first  accurately  to  describe  the 
changes  which  take  place  in  the  corneal  cells  in  inflammation,  and  to 
separate  tiie  newly-formed  cells  from  the  leucocytes.  He  showed  that 
wiicn  the  centre  of  the  cornea  was  cauterized  the  corneal  corpuscles 
immediately  around  the  eschar  were  killed  b}'  tiie  action  of  the  caustic. 
Tile  injury  to  tlie  tissue  extended  farther  tiian  the  formation  of  tiie 
eschar  seemed  to  indicate.  Tiie  necrotic  corpuscles  contracted,  tlieir 
processes  were  drawn  in,  and  tliey  became  converted  into  formless 
masses.  The  corpuscles  immediately  outside  of  this  area  underwent  other 
changes.  Tlicy  liecame  larger  and  stained  more  brigiitly,  the  nuclei 
increased  in  number,  and  long  jirocesses  were  given  off  from  tliem  wliicii 
extended  up  into  the  region  of  necrosis.  Nuclei  passed  from  tiie  cells 
into  tlicse  long  processes,  and  in  this  way  new  cells  were  formcfl  wliich 
took  the  place  of  necrotic  cells,  and  represented  not  an  inflammation, 
but  a  regeneration  of  the  tissue. 

These  changes  in  the  cells  only  take  place  in  the  corpuscles  adjacent 
to  the  necrosis,  and  no  changes  are  seen  in  tlie  cells  in  the  periphery 
where  the  pus-cells  are  entering  into  the  tissue.  It  has  been  shown 
that  it  is  possibl(»  to  produce  such  sliglit  injuries  to  the  tissue  that  tlicre 
is  little  or  no  infiltration  with  leueocytes,  and  tlie  clianges  may  be  limited 
to  regeneration  of  the  cells.  In  almost  any  sort  of  inflammation  in  any 
tissue  the  two  jirocesses  of  emigration  of  leucocytes  and  new  formation 
of  cells  take  place.  The  cellular  proliferation  takes  place  later  tlian 
the  emigration.  It  can  be  recognized  by  tiie  various  changes  whicli 
take  place  in  tlie  nuclei  preceding  cell-division,  and  in  general  does  not 
begin  until  two  to  four  days  after  the  receipt  of  the  injury.  The  eliarac- 
tcr  anil  tlie  arrangement  of  the  cells  can  be  easily  seen  in  the  small  foci 
of  inflammation  wliich  form  around  small  masses  of  bacteria  whicli  liave 
been  carried  as  emiioli  into  tlie  tissue.  Tliese  can  lie  produced  at  will 
by  the  injection  of  pure  cultures  of  tlie  staphylococcus  aureus  into  tlie 
ear-veins  of  rabbits,  and  tlieir  devcl(>])mcnt  observed  by  killing  the 
animals  at  successive  periods  after  the  injection.  Sucli  foci  will  serve  as 
general  types  of  acute  inflammation.  The  micrococci  are  found  in  a 
small  vessel,  either  a  capillary  or  a  small  vein,  wliicli  tliey  entirely  occlude. 
They  are  ])roI)ab!y  not  lodged  here  as  an  emliojus  filling  up  at  once  tlie 
entire  vessel,  but  one  or  more  lodge  in  tlic  endothelium  and  the  vessel 
becomes  filled  by  their  gro\\th.  In  tlie  older  foci  tlieir  growth  extends 
beyond  the  vessel,  and  clumps  of  tliem  may  be  found  in  the  tissue. 
Around  tlie  group  of  bacteria  tliere  is  a  distinct  necrosis  of  the  tissue. 
In  the  necrotic  mass  the  cells  may  sometimes  be  recognized,  Init  more 
generally  the  whole  is  converted  into  a  granular  mass.  In  the  periphery 
of  the  necrosis  the  tissue  is  infiltrati'd  witli  polvnuclear  leucocvtes. 
Tliese  form  a  wall  aronnd  and  extend  into  the  necrotic  tissue.  It  is 
probable  that  the  necrotic  tissue  is  formed,  to  some  extent  at  least, 
by  the  leucocytes  which  have  wandered  into  it  so  far  that  they  have 
fallen  victims  to  the  same  cause  which  jirodueed  the  necrosis  of  the 
tissue.     Although  the  wall  of  cells  formed  around  the  necrosis  is,  on 


166  SURGICAL  PATHOLOGY. 

the  inside,  composed  entirely  of"  leucocytes,  on  the  outside  these  gradu- 
ally give  place  to  mononuclear  cells  similar  to  the  indifferent  cells  of 
granulation  tissue  and  to  the  lymphoid  cells  of  the  blood.  The  more 
advanced  the  inflaniniatiun,  the  more  numerous  arc  they  in  the  tissue.  If 
tlie  animal  be  kille<l  twcnty-fbur  liours  after  injection  of  the  bacteria,  when 
the  small  inflanimatory  foci  arc  not  visii)lc  to  the  eve,  the  cells  may  lie 
absent.  Where  they  are  formed  in  the  tissues  is  a  question.  From  their 
close  relation  to  the  blood-vessels,  and  from  the  fact  that  in  the  cells 
forming  the  vessels  the  earliest  and  most  active  cell-proliferation  is  seen, 
it  seems  probable  that  they  arc  formed  from  these  cells.  In  some  of  the 
inflammations  produced  by  bacteria  they  may  be  so  numerous  as  to  con- 
.stitute  by  far  the  majority  of  the  new  cells.  Other  cells  make  their 
appearance  in  the  late  stages  of  inflammation,  but  they  are  so  obviously 
connected  with  repair  and  new  formation  of  tissue  that  they  will  be  con- 
sidered under  that  head. 

There  is  a  purpose  fulfilled  by  the  presence  of  the  leucocytes  in  the 
inflamed  tissue.  Whenever  there  is  any  dead  material  in  the  body,  this 
becomes  filled  with  leucocytes.  In  such  material  chemical  substances 
are  formed  which  exert  an  attracting  force  on  the  leucocytes.  In 
the  small  foci  of  inflammation  formed  around  masses  of  staphylococci 
they  are  attracted  not  only  by  the  necrotic  tissue  produced  by  the 
bacteria,  but  by  the  bacteria  themselves.  Capillary  tubes  partly  filled 
with  staphylococci  and  jtlaccd  in  the  tissues  speedily  become  filled  with 
leucocytes.  They  appear  to  pave  the  way  for  a  new  formation  of  tissue. 
It  is  by  means  of  the  leucocytes  that  the  detritus  of  dead  tissue  is 
removed.  In  the  acute  inflanunation  produced  by  bacteria  they  form  a 
wall  around  these,  close  up  the  lymphatics,  and  prevent  to  a  large  extent 
the  further  action  of  the  organisms.  JNIetschnikoff  has  shown  that  they, 
have  the  power  of  taking  up  and  destroying  bacteria,  and  their  presence 
is  in  this  way  a  source  of  protection  to  the  organism.  This  power  of 
eating  and  destroying  material  is  termed  "  phagocytosis."  Another 
purpose  which  they  serve  is  that  of  furnishing  food  to  the  large  epithe- 
lioid cells  which  are  concerned  in  the  f(5rmation  of  tissue.  There  can 
be  little  doubt  that  an  important  purjiose  may  also  be  served  by  the  fluid 
exudation  in  washing  out  solul)le  injurious  substances  from  the  tissues 
and  in  diluting  them.  INIost  foreign  bodies,  especially  those  of  an 
organic  character,  when  introduced  into  the  tissues,  Avill  produce  to  a 
limited  extent  inflammatory  changes  in  the  circulation  in  the  vessels 
around  them,  with  emigration  of  leucocytes  which  enter  into  the  foreign 
body.  Pieces  of  sponge  or  ])ith  placed  in  the  abdominal  cavity  become 
filled  with  leucocytes.  Other  substances  have  little  or  no  effect  in 
attracting  them.  Finely-powdered  glass  introduced  into  the  tissue 
causes  a  new  formation  of  tissue,  an  infiltration  with  round  lymphoid 
or  granulation  cells,  and  finally  a  capsule  formation ;  and  this  may  take 
place  without  the  emigration  of  a  single  leucocyte. 

Little  is  known  as  to  the  manner  in  which  the  red  corpuscles  pass 
through  the  walls  of  the  vessels,  and  the  conditions  favoring  this.  As 
a  general  rule,  the  more  severe  the  injury  produced  in  the  tissue,  the 
greater  is  the  number  which  ])ass  through.  They  cannot,  like  the  white 
corpuscles,  pass  through  by  their  own  active  movements,  and,  as  far  as 
can  be  seen  under  the   microscope,  they  pass  through  actually  intact 


INFLAMMA  TION.  167 

vessels.  It  may  be  that  from  the  dilatation  of  the  vessels  the  stomata 
beeome  so  large  that  they  are  forced  through  by  the  increased  pressure, 
or  small  fissures  not  visible  under  tlie  microscope  may  take  place  by 
means  of  which  they  make  their  escape.  When  in  the  tissues  they 
appear  to  take  no  active  part  in  the  changes  which  are  going  on.  In 
part  they  find  their  way  into  the  lymph-spaces  and  lymph-vessels,  and 
are  removed  by  the  lymph-stream.  In  part  they  are  taken  up  by  other 
cells,  and  may  contribute  to  the  nutrition  of  tiiese.  In  part  they 
remain  in  the  tissue  and  are  destroyed,  tlieir  pigment  being  taken  up 
by  the  cells. 

The  general  character  of  the  &*\elling  differs  greatly,  depending  on 
the  anatomical  structure  of  the  part  of  the  body  which  is  inflamed.  The 
so-called  parenchymatous  organs — as,  for  instance,  muscle,  kidney,  paro- 
tid and  other  glands — swell  in  toto  when  they  are  inflamed.  The  swell- 
ing is  proportional  to  the  degree  of  tiie  exudation.  It  Mill  be  more 
considerable  in  organs  which  are  surrounded  by  a  capsule  or  membrane 
which  is  capal)lc  of  distention  than  in  those  which  are  surrounded  by  a 
membrane  incapable  of  distention.  In  parenchymatous  organs  the  exu- 
dation is  in  the  meshes  of  the  interstitial  connective  tissue,  because  this 
tissue  carries  tlie  blood-vessels  and  is  more  easily  distended  by  fluid. 
In  the  inflammation  of  connective  tissue  the  exudation  accumulates  in 
its  meshes  ;  it  inflltrates  it.  In  a  furuncle  the  exudation  aceunudates  in 
the  loose  spaces  of  the  subcutaneous  tissue,  and  in  meningitis  it  accu- 
mulates in  the  spaces  of  the  pia-arachnoid.  The  same  is  seen  in  the 
substance  of  the  cornea  when  it  is  inflamed,  but  on  account  of  the 
sliglit  distensibility  of  this  tissue  the  thickening  in  the  beginning 
of  the  inflammation  is  not  a  very  marked  one,  and  the  inflltration 
appears  more  as  a  cloudiness  of  the  tissue  due  to  an  interference  with 
its  optical  2>roperties  than  as  a  swelling.  In  cartilage,  in  which  tiiere 
are  no  distensible  meshes  or  canals,  the  exudation-fluid  or  corpuscles 
cannot  enter  into  the  tissue ;  therefore  in  inflammation  of  the  cartilage 
of  joints  the  exudation  is  found  in  the  cavity  of  the  joint,  except  in  the 
immediate  periphery,  tiiere  under  certain  circumstances  a  few  corpuscles 
apparently  eat  tlicir  way  directly  into  the  tissue.  When  the  wall  of  a 
large  cavity  is  inflamed  the  inflammatory  exudation  accumulates  in  tlie 
cavity.  That  is  the  case  in  the  serous  membranes,  also  in  the  dura 
mater.  In  the  inflammation  of  periosteum  the  exudation  cannot  accu- 
mulate in  tlie  dense  tissues,  but  it  presses  in  beneatii  the  periosteum,  ele- 
vating it  from  the  bone.  The  inflammatory  exudation  always  accu- 
mulates where  it  finds  tiie  least  resistance ;  thus  in  ])neunionia  it  enters 
tiie  alveoli  of  the  lungs  and  fills  up  these,  because  it  finds  no  place  in  the 
alveolar  sejita.  In  the  same  way,  it  is  easily  understood  that  in  places 
where  a  dense  covering  prevents  the  exudation  reaching  the  free  surface 
this  covering  will  be  elevated  in  tiie  form  of  a  bladder  or  vesicle.  Tiiis 
is  seen  in  tlie  example  we  have  given  in  the  inflammation  of  the  peri- 
osteum, but  a  l)ettcr  example  is  given  in  the  inflammation  of  the  skin. 
In  all  forms  of  acute  inflammation  of  the  skin  one  of  the  most  common 
of  all  phenomena  is  to  find  the  epidermis  over  the  inflamed  area  elevated 
in  the  form  of  a  vesicle.  In  organs  which  freely  communicate  with  the 
outside,  and  an  open  way  is  given  for  the  exudation,  it  is  sinijily  poured 
out  on  the  surface  and  escapes.     This  is  the  case  with  all  mucous  mem- 


168  SURGICAL   PATirOLOdV. 

hi'iUK's,  beoausc  their  cpitlielial  cdvcriiiL!;  is  loose  ami  docs  not  hold  tlie 
exiidation  within  it  as  does  tiie  epidermis.  In  consequence  of  this  a 
formation  of  vesicles  does  not  take  place,  but  the  exudation  passes 
freely  tin-ough  to  tiie  surface.  This  is  also  tlie  case  in  the  kidneys, 
where  tiie  exudation  in  ))art  passes  otl'  in  the  urine  and  ajijjcars  in  the 
form  of  albumin. 

Inflammation  lias  l)een  divided  into  two  varieties,  depending  upon 
the  special  involvement  of  certain  elements  of  an  organ.  In  a  glandular 
organ  we  can  recognize  the  secreting  cells  and  the  connective-tissue 
framework  supporting  the  cells  and  carrying  the  blood-vessels.  Accord- 
ing as  the  special  seat  of  the  inflammation  was  supj)Osed  to  inv(dve  the 
specific  glandular  cells,  the  j)arent'hyina,  or  the  interstitial  tissue,  the 
division  has  been  made  of  parenchymatous  and  interstitial  inflamma- 
tion. This  division  is  a  false  one.  If  we  regard  inflammation  as  the 
sum  of  the  processes  which  take  place  in  the  tissues  on  receipt  of  an 
injury,  it  is  obvious  that  we  cannot  have  inflannnations  so  divided.  It 
is  hardly  possible  to  conceive  of  an  injury  which  will  affect  exclusively 
one  or  the  other  of  these  constituents  of  an  organ.  There  is  no  doubt 
that  under  certain  circumstances  there  may  be  accunndations  of  cells  in 
the  interstices  of  an  organ  due  to  growth  of  the  intercellular  tissue,  as 
in  some  of  the  pathological  conditions  met  with  in  the  kidneys  in  scarlet 
fever.  It  cannot  be  held  that  all  growth  in  connective  tissue  is  due  to 
regeneration  following  a  primary  lesion.  In  such  kidneys  there  are  few 
or  no  lesions  of  the  epithelium  of  the  tubules.  In  certain  liver  diseases 
a  similar  ])r(>liferation  of  the  connective  tissue  may  take  place.  AVe  have 
generally  been  accustomed  to  speak  of  such  ct)ntlitions,  in  which  we  find 
a  cellular  infiltration  of  the  tissue,  as  inflammation,  but  there  is  no  reason 
why  they  should  be  so  considered.  The  ])rolif'eration  of  the  connective 
tissue  may  be  due  to  the  direct  action  of  Iwcteria  or  their  chemical  jirod- 
ucts  on  the  tissue,  or  to  other  influences  producing  it  without  any  jire- 
ceding  injury. 

Inflanmiation  of  a  mucous  membrane  is  spoken  of  as  "catarrhal 
inflammation."  Virchow  used  the  name  to  denote  increase  of  func- 
tional activity  of  a  mucous  surface.  The  word  "catarrhal"  is  used  so 
loosely  that  it  is  difficult  to  define  it.  AVe  may  use  it  to  designate  mild 
degrees  of  infianunation  of  mucous  surfaces  in  which  there  is  neither 
idceration  nor  any  distinctly  characteristic  exudation,  sucli  as  a  fibrinous 
or  a  purulent  one.  In  inflammation  of  the  intestinal  canal  the  word 
is  generally  used  to  include  inflammations  the  etiology  of  which  is  un- 
known. The  increased  amount  of  fluid  which  comes  from  an  inflamed 
mucous  surface  has  two  sources.  In  the  first  ])lace,  the  mucous  mem- 
brane has  not  a  dense  tissue  on  the  surface  impervious  to  fluids,  like  the 
horny  layers  of  the  skin,  and  an  increased  amount  of  exudation  in  the 
subcutaneous  tissue  readily  finds  its  way  to  the  surface  instead  of  accu- 
mulating in  the  interstices  of  the  tissues.  A  mucous  surface  is  like  a 
serous  surface  in  this  respect.  In  the  next  place,  the  jjroper  secretion 
of  the  mucous  surface  is  increased.  This  is  in  part  due  to  the  hyj)cr- 
semia  of  vessels  su])plying  the  glands,  and  possibly  in  ])art  to  a  direct 
stimulation  of  the  glands  by  the  inflammatory  cause.  The  cells  may  be 
influenced  to  increased  action  in  the  .same  way  as  the  blood-vessels 
are.     In  most  cases  the  serous  exudation  from  the  vessels  of  the  tissue 


lyPLAMMATIOy.  169 

is  accoiiipanicfl  bv  emigration,  ami  the  leucocytes  pass  as  readily  through 
the  epithelial  layer  as  does  the  serum,  and  api)ear  in  the  Huid  on  the 
surface. 

A  more  suitable  classification  of  inflammation  is  one  based  on  the 
character  of  the  exudation.  The  character  of  the  exudation  is  largely 
determined  by  the  cause  of  the  inflammation  and  the  intensity  of  its 
action.  The  causes  are  so  manifold  that  it  would  be  impossible  to  give 
an  etiological  classification.  Tlie  exudation  in  inflammation  may  be 
almost  entirely  serous,  and  such  inflanmiations  arc  sjioken  of  as  edema- 
tous or  serous  inflammations.  In  any  inflammation  the  (piantity  of  serous 
exudation  is  increased.  The  tissue  in  serous  inflanunation  is  infiltrated 
with  fluid.  The  increased  transudation  represents  the  reaction  of  the 
tissue  to  a  mild  injury.  One  of  the  best  examples  of  it  is  the  inflam- 
mation of  tile  skin  which  follows  prolonged  exposure  to  the  sun.  The 
injection  of  tlie  vessels  is  extreme  and  the  skin  is  swollen  and  pits  on 
pressure.  Most  of  tlie  exudation  accumulates  in  the  meshes  of  the 
tissue,  but  a  certain  portion  passes  to  the  surface  and  elevates  the  epider- 
mis in  the  form  of  smaller  or  larger  vesicles.  The  vesicles  are  filled 
with  a  clear  transparent  fluid  which  on  microscopic  examination  shows 
few  cellular  elements.  If  the  cause  be  removed,  the  contents  of  the 
vesicles  will  be  absorbed.  The  action  of  the  sun  has  probaljly  been  to 
produce  sliglit  injury  of  tlii'  upper  layers  of  the  epidermis,  in  some  cases 
extending  more  or  less  deeply  into  the  tissues  below.  In  some  cases 
extensive  necroses  e.xtendiiig  through  the  skin,  which  are  followed  by 
all  the  phenomena  of  intense  inflammation,  may  be  produced.  There  is 
increased  serous  transudation  in  the  beginning  of  every  inflammation. 
In  pneumonia,  congestion  and  <edeiiia  of  the  lung  preceile  the  formatiiin 
of  the  fibrinous  exudation.  In  every  wound  a  clear  fluid  first  exudes 
which  contains  but  few  corpuscles,  and  which,  coagulating  in  a  thin 
layer  on  the  surface,  produces  the  glazing.  The  oedematous  inflammation 
may  also  represent  the  end  or  limit  of  the  process.  In  a  furuncle,  out- 
side of  the  central  necrosis  and  leucocytic  infiltration,  the  tissues  are 
infiltrated  with  serous  fluid,  and  a  subcutaneous  ledema  is  often  found 
accompanying  acute  inflammation  of  the  costal  pleura. 

In  any  inflammation  there  is  an  increased  amount  of  fibrin  in  tlie 
exudation  as  compared  with  the  normal  (Fig.  5).  The  fluid  in  the  tissue 
in  cedematous  inflammation  contains  more  fibrin  than  when  the  exudation 
is  increased  from  some  other  cause,  as  from  chronic  passive  congestion. 
The  fibrin  may  accumulate  in  tiie  tissue  and  give  rise  to  a  dense,  brawny 
induration.  The  amount  of  fibrin  is  to  a  certain  extent  dependent  upon 
the  severity  of  the  inflammatory  cause  of  the  injury.  As  a  general 
rule,  the  greater  tlie  degree  of  necrosis  the  more  extensive  will  be  the 
formation  of  fibrin.  .The  elements  for  the  formation  of  fibrin  are 
present  in  the  exudation,  and  tlie  necrotic  cells  supply  the  fibrin-ferment. 
To  a  much  greater  extent  the  formation  of  filirin  seems  to  depend  upon  the 
nature  of  the  agent  which  produces  the  inflammation.  The  most  typical 
fibrinous  inflammation  is  seen  in  acute  croupous  pneumonia.  Even  in 
the  rabbit,  when  inoculated  subcutaneously  with  the  organism  which 
causes  this  disease,  a  fibrinous  exudation  may  be  produced  which 
may  extend  over  the  centre  of  the  abdomen.  It  is  possible  that  sub- 
stances may  be  produced  by  these  organisms  which  have  an  analogous 


170  suRorrAL  pathology. 

action  to  the  fibrin-ferment.  Sucli  iiiilnimnation.s,  characterized  hv  an 
excessive  amount  of  fibrin  in  the  exudation,  are  spoivcn  of  as  fiI)rinons 
inflammations.  The  term  is  more  <;-cncrally  used  to  specially  character- 
ize fibrinous  exudations  on  surfaces  of  the  body.  Such  exudations  are 
always  accompanied  by  necroses,  and  are  called  diphtheritic.  Formerly 
a  distinction  was  made  between  croupous  and  diphtheritic  inflamma- 
tions. In  the  croupous  infiammations  the  exudation  was  supposed  to 
be  seated  on  the  surface  of  relatively  intact  mucous  membranes.  In 
the  diphtheritic  inflammations  tiie  exudation  was  supposed  to  extend 
from  the  surface  into  the  meshes  of  the  tissue.  The  croupous  exudation 
could  be  peeled  as  a  membrane  from  the  surface,  leaving  it  intact ;  tlie 
dij)htheritic  could  not  be  removed  without  the  production  of  a  loss  of 
substance.  The  only  difference  between  the  processes  is  one  due  to  the 
anatomical  character  of  the  surface.  In  both  cases  there  is  necrosis  of  the 
.surface  epithelium,  and  the  exudation,  ctiming'  in  contact  with  the  necrotic 
tissue  which  furnishes  an  abundent  suj)ply  of  fibrin-ferment,  coagulates. 
The  exudation  can  be  easily  removed  as  a  membrane  on  surfaces  having 
a  dense  basal  membrane  beneath  the  epithelium.  It  is  not  removed 
from  the  surface  of  the  epithelium,  but  is  removed  with  the  ejiithe- 
lium.  The  exudation  cannot  be  rt'Uioved  from  the  surface  \\here  there 
is  no  basal  membrane  beneath  the  eiiithelium,  in  which  case  the  union 
of  the  epithelium  with  the  tissues  beneath  is  more  direct.  In  this  ease 
the  fibrin  also  extends  down  into  the  tissue  beneath,  and  there  is  a  close 
union  with  the  fibrin  on  the  surface  and  that  in  the  tis.sues,  aiid  it  cannot 
be  removed  as  a  mass.  The  difference  between  the  two  is  easily  seen  in 
diphtheria.  When  the  disease  is  localized  in  the  pharynx  the  membrane 
cannot  be  removed.  If  in  the  larynx  an<l  trachea,  it  can  be  removed, 
sometimes  representing  a  perfect  cast  of  these  parts.  The  term  "diph- 
theritic inflammation  "  is  simply  an  anatomical  one,  and  has  no  necessary 
relation  to  the  infectious  disease  diphtheria.  This  disease  is  charac- 
terized by  a  fibrinous  exudation  on  the  surfaces  affected,  combined 
with  necrosis.  It  is  very  probable  that  here,  just  as  in  the  fibrinous 
exudation  in  pneumonia,  the  character  of  the  exudation  is  due  in  great 
part  to  the  specific  agents  which  cause  the  disease.  In  some  cases  the 
membrane  is  much  more  extensive  than  in  others,  and  it  may  be  pro- 
duced, though  generally  not  to  the  same  degree,  by  other  agents  than  the 
diphtheria  Ijacilli.  Inflammations  of  the  same  parts  caused  by  some  of 
the  ]ius-()rganisms,  and  even  by  the  ap])lication  of  chemical  agents  which 
will  produce  a  necrosis  on  the  surface,  may  be  accomjianicd  by  mem- 
brane-formation. The  filirin  on  the  surface  does  not  come  exclusively 
from  the  exudation.  The  epithelium  itself  undergoes  a  form  of  necrosis 
which  is  combined  with  coagulation  of  the  protoplasm  of  the  cell,  and  a 
reticular  mass  is  formed  largely  com])osed  of  the  fibrinoid  metamorphosis 
of  the  cells.  The  fibrin  in  these  exudations  does  not  always  have  the 
same  character.  In  the  tissues  the  fibrin  usually  appears  in  the  form  of 
extremely  fine  filaments.  On  the  surface  it  may  appear  in  the  form  of 
large  hyaline  masses  or  as  a  definite  reticulum.  In  all  of  the  mucous 
surfaces  this  form  of  inflammation  is  frequently  observed.  In  the  large 
intestines  it  forms  one  of  the  anatomical  varieties  of  dysentery.  On 
o])en  wounds  a  fibrinous  inflammation  leading  to  the  production  of  dense 
membranes  is  not  infrocjuently  observed.     It  may  be  due  to  infection  of 


INFLAMMATION.  171 

tlio  wound  with  certain  specific  niicro-organi.sm.s.  In  cases  of  diplitlieria 
any  open  wound  of  the  body  is  liable  to  Ijecome  infected  with  the  organ- 
isms of  the  disease,  and  a  tyijical  membrane  may  be  formed  over  the 
wound.  I  have  seen  two  cases  in  which  the  infection  of  wounded  sur- 
faces resulted  from  accidental  inoculation.  In  one  there  was  a  fissure  of 
the  anus  which  became  so  infected,  and  in  the  other  a  paronychia  about 
the  small  toe  became  infected.  In  both  the  characteristic  organisms  were 
obtained  from  cultures.  In  the  uterus  a  diphtheritic  membrane  with 
extensive  necrosis  of  the  surface  forms  one  of  the  lesions  fountl  in  puer- 
peral infection.  Here  the  condition  is  in  nearly  all  cases  due  to  the 
presence  of  one  of  the  pus-organisms,  the  streptococcus.  Fibrinous  in- 
flannnations  are  also  foimd  on  the  serous  surfaces,  and  they  seem  to  take 
place  more  readily  here  than  in  any  other  part  of  the  body.  The  fibrin 
is  deposited  both  on  the  surface  covering  the  viscera  contained  in  the 
cavity  and  on  that  lining  the  walls,  ^^'here  these  two  surfaces  move  over 
one  another,  as  in  the  pericardium,  the  constant  adhesion  and  separation 
give  rise  to  a  roughening  of  the  surface,  causing  the  appearance  which 
has  been  compared  with  that  pro<luced  by  the  separation  of  two  pieces 
of  bread  and  butter.  In  serous  membranes  the  fibrinous  infiammation 
is  in  part  due  to  a  greater  degree  of  intensity  in  the  action  of  whatever 
produces  the  inflammation.  The  same  agent  acting  in  ditferent  degrees 
of  strength  can  at  one  time  produce  a  simple  serous  exudation  and  at 
another  a  fibrinous  exudation.  When  two  surfaces  covered  with  a 
fibrinous  exudation  come  in  contact  with  one  another,  adhesions  are 
formed  from  the  intermingling  of  the  fibrillar  of  fil)rin  on  the  two  sur- 
faces. In  filn'inous  inflammation  of  the  peritoneum  the  adjacent  surfaces 
of  the  viscera  become  adherent.  The  fibrinous  exudation  sometimes 
serves  in  this  way  a  useful  purpose  in  uniting  wounds.  The  primary 
adhesion  of  a  simple  wound  is  due  to  this  intermingling  of  the  exudation 
from  the  opposing  sides  of  the  wound. 

HeuKirrhagic  inflammation  is  spoken  of  when  the  exudation  contains 
large  numbers  of  red  blood-corpuscles.  This  character  of  inflammation 
may  be  due  to  a  specific  action  of  some  agent  producing  the  inflamma- 
tion, or  it  is  due  to  constitutional  anomalies  on  the  part  of  the  individual. 
Thus  in  scurvy  and  purpura  an  inflammation  which  under  ordinary  cir- 
cumstances would  be  serous  only,  may  become  hemorrhagic.  The  con- 
stitutional anomaly  is  due  either  to  a  condition  of  the  lilood-vcssels  which 
allows  the  red  blood-corpuscles  to  pass  through  them  more  readily  or 
possibly  to  changes  in  the  blood  itself. 


PtmtrLENT  Inflammation. 

This  is  a  form  of  inflammation  Avhich  is  sliarjdy  separateil  from  the 
others,  and  is  characterized  by  an  exudation  whicii  is  callcil  pus.  In 
other  forms  of  inflanmiation  the  exudations  may  differ,  depending  upon 
the  action  of  different  causes  or  upon  a  greater  or  less  intensity  in  the 
action  of  the  same  cause.  We  can  have  from  the  same  cause  acting  in 
varying  degrees  of  intensity  a  serous,  a  fibrinous,  or  a  hemorrhagic 
exudation.  By  subjecting  the  ear  of  a  rabbit  to  water  at  different 
degrees  of  temperature  all  the  various  forms  of  inflammation  may  be 


172  SUBGICAL   PATIIOLOOY. 

produced,  with  the  exception  nt'  tlir  puriilont.  This  cannot  be  pnxkiced 
by  the  action  of  the  most  intense  caustics. 

Pus  is  a  whitish  or  g-ravisli  (>i)a((ue  fluid  of  varying  degrees  of  density. 
It  may  acquire  a  reddisii  tinge  from  an  aihnixture  of  red  corpuscles ;  in 
some  cases  it  has  a  distinctly  j'ellowish  or  bluish  tinge,  the  latter  being 
due  to  certain  of  the  bacteria  which  cause  suppuration.  The  exudation 
may  infiltrate  in  the  tissues — that  is,  it  may  be  contained  in  the  meshes 
of  the  tissues,  as  in  the  serous  exudation — or  it  may  be  contained  in 
cavities  which  are  hollowed  out  in  the  tissues.  8uch  a  cavity  containing 
pus  is  called  an  abscess.  Or,  again,  there  may  be  a  loss  of  substance  on 
the  surface  from  which  such  a  fluid  exudes.  In  all  other  forms  of 
inflammation,  particularly  in  the  more  severe  forms,  there  is  more  or  less 
fil)rin  in  the  exudation.  In  the  purulent  inflammation  the  exudation 
contains  either  no  fibrin  at  all  or  only  a  small  amount  of  it.  Moreover, 
the  exudation  differs  in  the  eftect  which  it  has  on  the  tissues  of  the 
inflamed  part.  In  the  serous  and  fibrinous  inflammations  the  exudation 
either  accumulates  in  the  interstices  of  the  tissue,  or,  if  it  cannot  be  con- 
tained in  this,  it  passes  to  the  surface  or  into  the  natural  cavities  of  the 
body,  always  following  the  path  of  least  resistance.  The  exudation  in 
itself  seems  to  produce  no  injury  to  the  tissue.  The  tissue,  of  course, 
may  be  injured  by  having  its  nutrition  interfered  with  by  compression 
of  vessels  produced  by  the  exudation,  and  very  extensive  necrosis  may 
be  produced  in  this  way ;  but  the  exudation  in  itself  produces  no  injurious 
action  on  the  tissues  with  which  it  comes  in  contact.  The  purulent 
inflammation  is  different.  In  this  there  is  not  only  destruction  of  cells 
by  the  exudation  surrounding  them,  l)ut  the  intercellular  substance  itself 
is  destroyed  and  dissolved  by  the  exudation.  The  exudation  and  the 
softening  and  destruction  of  the  tissue  combine  to  form  the  abscess.  The 
dissokition  of  the  intercellular  substance  takes  place  more  easily  in  the 
loose  areolar  tissue.  Not  only  is  this  solvent  action  of  the  exudation 
exerted  on  the  intercellular  substance,  but  the  fibrin  also,  when  any  is 
present,  is  dissolved  in  it. 

"We  can  easily  follow  the  course  of  development  of  an  abscess  by 
injecting  some  of  the  bacteria,  which  from  their  specific  action  are 
spoken  of  as  the  pus-organisms,  into  the  ear-vein  of  a  rabbit.  The 
organisms  are  carried  into  various  tissues,  and  by  their  growth  form 
small  masses  in  these.  The  first  ett'ect  of  the  presence  of  the  organisms 
is  the  production  of  necrosis  in  the  tissue  innnediately  surrounding  them. 
This  is  accompanied  by  an  enormous  emigration  of  leucocytes  extending 
into  the  necrotic  tissue,  and  the  leucocytes  to  a  great  extent  undergo  the 
same  necrosis  as  the  tissue.  In  the  pcri]ihery  they  form  a  more  or  less 
distinct  wall  around  the  necrotic  tissue.  In  the  necrotic  area  itself  there 
is  of  coui-se  no  inflammation.  Not  only  are  the  cells  destroyed,  but  the 
blood-vessels  as  well,  and  no  circulation  takes  place  within  the  jiart.  The 
next  stage  in  the  formation  of  the  abscess  is  the  liquefiiction  of  the  tissue. 
The  bacteria  or  their  chemical  products  appear  to  exert  an  actual  dissolv- 
ing power  on  the  tissue.  First,  apjiarently,  the  intercellular  substance  is 
dissolved,  and  all  of  the  cells,  both  those  of  the  tissue  and  the  leucocytes, 
come  together  to  form  a  single  mass.  Sometimes  the  tissue-cells  more  or 
less  retain  their  fcn-m  and  can  be  recognized,  but  more  often  they  are 
broken  up  into  fragments  or  granules.     In  some  cases  the  suppuration 


INFLAMMATION.  173 

does  not  spread  from  a  single  point  in  tliis  way,  but  from  several  adjacent 
points.  Then  the  various  foci  of  softening  come  together,  forming  a  single 
cavity,  which  may  contain  not  only  the  individual  cells  which  have  been 
set  free  by  the  dissolution  of  the  intercellular  substance,  but  larger 
masses  of  tissue  into  which  the  softening  has  not  fully  extended,  and 
which  are  set  i'ree  by  the  various  foci  of  softening  meeting  one  anotiicr. 
The  various  tissues  show  a  varying  resistance  to  this  softening  power  of 
the  exudation.  In  a  glandular  organ  the  comiective-tissue  septa  in  the 
gland  offer  the  least  resistance.  The  suppuration  may  extend  along 
these,  and  an  abscess  be  formed  which  will  ct)ntain  large  necrotic  masses 
of  the  glandular  substance.     Such  masses  are  spoken  of  as  sloughs. 

The  pus  varies  in  consistence.  Sometimes  it  is  thick  and  creamy,  at 
others  it  is  thin  and  similar  to  a  serous  exudation.  The  cells  are  to  a 
large  extent  the  white  corpuscles  of  the  blood.  Of  course  along  with 
these  cells  there  will  be  otlier  cells  and  fragments  of  cells  which  come 
from  the  tissues.  When  the  pus-cells  are  examined  on  the  warm  stage 
of  a  iuicrosco]ic  many  of  them  show  acti\-o  amreboid  movements.  The 
fluid  portion  of  the  pus  is  simply  the  serous  exudation.  The  pus  con- 
tiiined  in  a  definite  abscess-cavity  is  frequently  under  considerable  ten- 
sion, sometimes  apjiarently  much  higher  than  the  blood-pressure.     On 

Fig.  6. 


m 


c 


b 


'.■■■>.:. 

'^.sli^iili 

■y'^f^yM'' 

^p^,^:;.^.:.| 


Section  of  a  chronic  abscess  of  the  lung :  a,  layer  of  pfrannlar  material  composed  of  necrotic  cells 
and  bacteria;  b.  layer  of  tissue  tilled  with  leucocytes:  c,  loose  granulation  tissue  contiunine 
dilated  blood-vessels,  from  wliicli  active  emigration  is  taking  place ;  d,  denser  cicatricial 
tissue. 

making  an  incision  into  an  abscess  the  contents  may  spurt  to  a  consider- 
able distance.  When  the  abscess-cavity  has  remained  for  some  time  a 
definite  wall  is  formed  around  it,  which  prevents  its  further  extension 
(Fig.  6).  As  the  abscess  is  forming  there  is  constantly  going  on  outside 
of  the  necrosis  antl  outside  of  the  wall  of  leucocytes  a  gro\\th  of  the 
tissue.  All  of  the  cells  of  the  tissue,  the  connective-tissue  cells,  those 
forming  the  walls  of  the  blood-vessels,  and  ]>robal)ly  also  the  specific 
cells  of  the  tissue,  proliferate.  In  consequence  of  this  proliferation 
there   is  produced  a  dense  tissue  consisting  to  a  large  extent  of  cells 


174  SURGICAL  PATHOLOGY. 

■similar  to  the  lymphoid  cells  of  the  hlood.  This  is  the  sjime  tissue 
which  forms  the  small  projeeting  granules  seen  on  the  surface  of  an 
ulcer,  and  from  this  it  has  received  tlic  general  name  of  granulation 
tissue.  Sometimes  softening  does  not  take  place  until  such  a  definite 
wall  is  formed  around  the  focus.  This  action  on  the  part  of  the  tissue 
varies  in  different  cases.  Sometimes  it  is  almost  entirely  absent,  and 
there  is  nothing  oj)posed  to  the  extension  of  the  ])rocess.  In  some  cases 
it  would  a])pear  as  tiiough  there  were  a  direct  excitation  of  cell-]MX)lifcr- 
ation  of  the  tissues  produced  by  the  bacteria.  Such  a  membrane  lining 
an  abscess  is  called  a  "pyogenic  membrane."  It  is  a  soft  reddish  mem- 
brane having  a  slight  similarity  to  a  mucous  surface.  It  was  formerly 
supposed  that  pus  could  be  directly  secreted  by  such  a  membrane.  It 
always  contains,  along  with  the  cells  derived  from  the  tissue,  a  large 
number  of  leucocytes,  which  are  constantly  passing  through  it  into  the 
abscess,  and  in  the  vessels  not  only  of  the  membrane  itself,  but  in  those 
of  the  surrounding  tissues,  there  are  quantities  of  leucocytes.  In  many 
cases  the  membrane  does  not  -offer  sufficient  opposition  to  the  advance  of 
the  suppurative  pi'ocess.  The  cells  composing  it  may  become  necrotic, 
soften,  and  form  part  of  the  contents  of  the  abscess,  and  its  formation 
gradually  recedes  as  it  is  gradually  destroyed.  There  is  no  sharp  limit 
to  the  membrane-f(jrmation,  but  it  gradually  fades  off'  into  the  surrountl- 
ing  tissues.  For  a  considerable  distance  around,  the  formation  of  gran- 
ulation tissue  continues,  appearing  as  an  infiltration  of  the  interstitial 
tissue  with  small  round  cells.  Sometimes  the  purulent  inflammation  is 
preceded  by  a  fibrinous  or  serous  inflammation.  The  fibrinous  inflam- 
mation of  a  serous  surface  may  become  changed  into  a  purulent,  and  the 
fibrin  which  has  been  formed  becomes  dissolved  in  the  pus.  There  may 
be  a  large  amount  of  fibrin  in  the  tissue  surrounding  an  abscess  which 
may  become  softened  by  the  advance  of  the  suppuration. 

We  may  distinguish  various  sorts  of  abscesses,  depending  on  the  cha- 
racter of  the  pus  and  the  character  of  the  tissue  in  which  it  is  formed. 
When  an  abscess  forms  rapidly  and  is  accompanied  by  a  considerable 
amount  of  jiain  and  evidences  of  acute  inflammation,  it  is  spoken  of  as 
an  acute  or  a  hot  abscess.  On  the  other  hand,  the  abscess-formation 
may  take  place  slowly,  the  pus  may  accunudate  slowly,  and,  if  this 
takes  place  in  an  organ  poorly  supplied  with  nerves,  it  may  not  give 
rise  to  any  special  symptoms.  Again,  the  pus  may  be  formed  in  one 
portion  of  the  body,  and  may  by  gravity  extend  into  a  jiortion  lower 
down,  gradually  dissolving  the  tissue  as  it  passes  along.  Such  an 
abscess  is  called  a  cold  or  gravity  abscess.  One  of  the  best  examples 
of  this  is  the  abscess  which  appears  in  the  inguinal  region,  the  pus 
being  formed  in  the  vertebra?  and  descending  along  the  psoas  muscle. 

The  amount  of  pain  in  purulent  inflammation  differs  greatly.  In 
feome  cases  it  is  intense  ;  it  others  it  may  be  entirely  al>sent.  This 
depends  largely  upon  the  character  of  the  tissue  and  the  amount  of 
nerves  in  the  part.  In  an  abscess  of  the  subcutaneous  tissue,  where 
pressure  is  exerted  on  the  nerves  of  the  skin,  the  pain  may  be  intense. 
In  abscesses  in  internal  organs  poorly  supplied  with  nerves,  as  in  the 
liver,  a  large  abscess  may  be  formed  without  any  pain  accompanying  it. 
The  pain  will  also,  as  in  an  ordinary  inflanunation,  depend  upon  the 
amount  of  pressure  which  is  exerted  on  the  nerves.     In  a  tissue  capable 


INFLAMMA  TION.  1 7  5 

of  distention  there  will  be  less  pain  than  in  a  firm,  dense  tissue.  Ab- 
scesses of  bone  and  of  the  periosteum  are  accompanied  by  intense 
jiain.  The  amount  of  i)ain  will  also  depend  upon  the  rapidity  with 
which  the  abscess  is  formed.  If  the  pus  accumulates  rapidly,  the  pain 
will  1)C  more  intense ;  if  it  accunuilatcs  slowly,  the  tissues  can  gradually 
become  accustomed  to  the  ihstcntion. 

Inflammation  produced  by  Bacteria. 

The  action  of  almost  all  pathogenic  bacteria  is  closely  related  to 
intlammation,  because  such  bacteria  in  general  produce  an  injury  to  the 
tissue  where  they  are  present.  The  inflannnations  which  arc  produced 
by  bacteria  are  also  in  some  ways  ditferent  from  the  chemical  or  mechan- 
ical inflammations.  Bacteria  may  act  on  the  body  in  a  vai'iety  of  ways. 
In  the  first  place,  the  organisms  may  enter  directly  into  the  blood,  and 
there  find  suitable  conditions  for  their  growth,  or,  without  growing 
in  the  blood,  may  be  deposited  by  it  in  the  ditferent  organs.  In 
most  cases  there  is  a  primary  lesion  produced,  and  the  infection  of 
the  blood  follows  from  this.  In  consequence  of  this  the  bacteria  may 
be  deposited  in  the  various  organs  of  the  body,  and  foci  similar  in  their 
general  nature  to  the  primary  focus  of  infection  may  be  formed.  A 
distinction  must  be  made  between  the  cases  in  which  the  organisms  grow 
in  the  blood  and  the  cases  in  which  they  may  enter  the  blood,  l)ut  do  not 
find  there  suitable  conditions  for  their  growth,  and  the  blood  simply  acts 
as  a  carrier,  depositing  them  in  various  organs,  where  they  exert  a  local 
action.  When  the  organisms  enter  into  the  blood  the  condition  of  septi- 
cemia is  produced.  Many  of  the  pus-organisms  have  the  power  of  infect- 
ing the  blood,  and  septicemia  is  most  frequently  found  as  an  accompani- 
ment to  some  one  of  the  purulent  affections.  In  many  cases  the  danger 
of  septicfemia  seems  to  stand  in  inverse  relati(jn  io  the  extent  of  the  pri- 
mary infection.  The  more  develojjed  the  local  infection,  the  less  apt 
the  septicemia  is  to  take  place.  Frequently  the  same  organism  which 
causes  a  typical  local  disease  in  one  animal  will  produce  septicemia  in 
another.  In  man  inoculation  with  the  anthrax  bacillus  will  always 
produce  an  intense  local  inflammation  at  the  point  of  inoculation,  the 
anthrax  pustule,  which  is  only  exceptionally  followed  by  septicemia. 
Most  of  the  local  lesions  produced  by  bacteria  are  distinctly  infianuna- 
tory  in  character.  This  is  eminently  the  case  in  most  of  the  acute 
infectious  diseases ;  for  instance,  in  anthrax,  in  diphtheria,  in  pneu- 
monia. ]\Iany  of  the  inflammations  so  jiroduced  are  j>urulent  in  cha- 
racter. In  other  cases  lesions  very  closely  related  to  inflammation,  or 
which  at  scmie  period  of  their  course  arc  accomiianicd  by  inflammatinn, 
will  be  produced.  The  lesions  which  arc  produced  by  the  tubercle 
bacillus  and  by  the  typhoid  ba^'ilhis  arc  at  first  not  inflammatory  in 
character.  The  lesions  consist  in  a  new  formation  of  tissue  of  a  definite 
type,  which  arises  from  proliferation  of  the  fixed  cells  of  the  tissue.  In 
the  bi'ginning  of  these  formations  then;  may  be  n(j  emigration  of  leuco- 
cytes and  no  inflammatory  lesions  in  the  tissue.  At  a  later  period, 
however,  in  each,  necrosis  and  degeneration  take  place  in  this  newly- 
formed  tissue,  and  with  this  the  inflammatory  phenomena  begin.  In 
ty])hoid  fever  the  lesions,  in  the  first  place,  consist  of  a  new  formation 


17G  SURGICAL  PATHOLOGY. 

of  lym])lioid  tissue  arisinti;  from  tliu  lyiiiplioid  tissue  of  the  iutestiual 
canal.  lu  this  lymphoid  tissue  there  are  no  leueoeytes,  and,  althdugli 
tliere  may  be  hyperceniia  of  the  surrounding  biood-vessels,  there  is  no 
emigration  of  leucocytes  and  no  increased  exudation.  It  is  only  when 
necrosis  takes  place  in  the  hyperplastic  tissue  that  the  invasion  of  leuco- 
cytes begins.  The  .same  is  true  in  tubercle.  Emigration  only  begins 
and  leucocytes  are  only  found  in  the  tuberculous  tissue  when  caseation 
appears.  The  necrosis  whicli  arises  in  a  specific  tissue  in  this  way  appar- 
ently has  the  same  attraction  for  the  leucocytes  as  has  necrosis  of 
normal  tissue.  The  same  thing  is  true  of  the  new  formations  not  caused 
by  bacteria.  Many  of  the  tumors  are  accompanied  by  intlanmiation  in 
the  surrounding  tissues,  and  even  in  the  tumor  itself  there  may  be  emi- 
gration, an  increased  exudation  from  the  blood-vessels ;  and  this  is 
closely  connected  witli  processes  of  degeneration  in  the  tumor.  These 
processes  may  be  related  to  inflammation  in  another  way.  Thus  the 
tubercle  may  excite  inflanunation  merely  by  its  presence.  It  may  pro- 
duce by  its  presence  injuries  in  the  ti.ssue  which  will  be  followed  by 
inflammation,  and  which  may  not  be  immediately  connected  with  the 
bacteria. 

The  character  of  the  inflammations  produced  by  bacteria  will  be 
largely  influenced  by  the  manner  in  A\hieh  these  gain  entry  into  the 
system.  This  may  take  place  in  various  ways.  They  may  enter  into 
the  tissues,  producing  an  inflammation  at  the  point  at  which  they  enter, 
or  they  may  produce  no  local  lesions  at  the  point  of  entry,  and  be 
carried  by  the  blood  to  various  tissues  of  the  body  and  deposited  there, 
only  producing  lesions  in  the  tissues  for  which  they  have  a  specific 
aflinity,  which  is  probably  due  to  tlie  fact  that  certain  tissues  offer  them 
the  mo.st  suitable  conditions  for  their  growth.  This  is  the  case  in  small- 
pox and  in  scarlet  fever.  Although  we  do  not  know  anything  about 
the  virus  of  small-pox  or  of  scarlet  fever,  it  is  exceedingly  improbable 
that  the  lesions  of  the  disease  could  be  produced  by  bacteria  finding 
entry  through  the  skin.  The  same  bacteria  do  not  always  act  in  the  same 
way.  In  general  we  are  able  to  surmise  from  the  character  of  an 
infiannnation  what  is  the  s{)ecific  organism  which  has  caused  it ;  but 
there  are  exceptions  to  this.  The  .same  organism  whicli  causes  a  typical 
fibrinous  inflammation  in  the  lungs  may  under  some  circumstances 
produce  a  distinctly  purulent  inflammation  Mithout  any  formation  of 
fibrin  at  all.  One  of  the  ])us-urganisms,  the  streptococcus,  may  pro- 
duce in  the  pharynx  as  typical  a  fibrinous  infiannnation  as  is  produced 
by  the  diphtheritic  bacillus,  while  under  other  conditions  it  may  form 
an  abscess.  The  bacteria  may  also  be  related  to  inflammation  in 
another  way.  They  may  produce  local  lesions,  and  there  may  be 
]>roduccd  in  these  local  lesions  chemical  poisons  which  will  ]n'oduce 
necrosis  and  degeneration  in  distant  organs,  and  these  may  be  followed 
by  inflammatory  phenomena.  The  most  typical  inflannnations  are  ])ro- 
duced  by  a  group  of  organisms  which  are  so  closely  related  to  sup])uration 
that  they  are  called  the  pyogenic  or  "  pus-organisms."  Suppuration  may 
under  certain  circumstances  al.so  be  produced  by  a  nimiber  of  other 
organisms.  The  essential  pus-organisms  are  the  staplu/lococcus  aureus, 
the  streptococcus  pyogenes,  the  sfapht/lococcus  cpklermidis  albus,  the 
bacillus  pyogenics  fcetidus,  and  the  bdci/lus  pyocyaneus.     In  addition  to 


INF  LA  MM  A  TION.  Ill 

these  suppuration  has  frequently  been  found  to  be  pi'oduced  by  other 
organisms  ;  for  instance,  by  the  colon  bacillus,  by  the  tubercle  bacillus, 
by  the  clip/ococcus  lanceolatus,  l)y  the  baci/hui  proteus,  and  by  various 
others.  The  most  typical  purulent  inflammations  are  those  produced  by 
the  staphylococcus  and  the  streptococcus.  In  the  case  of  the  staphylo- 
coccus its  action  has  been  thoroughly  investigated  by  experiments  both 
on  man  and  animals.  The  most  typical  influnnuation  in  man  produced 
by  it  is  the  ordinary  boil  or  furuncle.  In  this  it  is  evident  that  the 
bacteria  find  their  way  into  the  skin  along  the  hair-follicles  or  the 
sebaceous  glands.  It  has  been  found  that  the  mere  application  of  the 
organisms  to  the  surface  of  the  skin  is  not  followed  by  any  results. 
When  they  are  rubbed  into  the  skin  the  typical  furuncle  may  be 
produced.  They  apparently  do  not  enter  into  the  skin  by  means  of  the 
sweat-glands,  and  furuncles  do  not  appear  on  the  parts  of  the  body 
where  there  are  no  hair-follicles  or  sebaceous  glands,  as  ou  the  jialni 
of  the  hands  or  the  soles  of  the  feet.  They  are  most  apt  to  a])pear  on 
portions  of  the  body  which  are  subjected  to  the  rubbing  of  clothing,  as 
at  the  back  of  the  neck  and  the  waist-line.  There  is  first  produced  a 
necrosis  of  the  tissue  in  the  neighborhood  of  the  hair-follicles  or  gland, 
and  around  this  suppuration.  The  necrotic  tissue  which  produces  this 
does  not  always  li([uefy,  but  remains  as  the  so-called  core  of  the 
furuncle  which  is  cast  out  with  the  pus.  The  pus  produced  by  the 
staphylococcus,  as  a  rule,  is  thick  and  creamy,  fi'equently  M'ith  a 
distinctly  yellowish  color,  probably  due  to  the  pigment  produced  by  the 
organisms  in  their  growth.  The  streptococcus  has  a  greater  variety  in 
its  action  than  the  staphyhjcoccus.  The  streptococcus  may  produce  on 
the  surface  of  mucous  membranes  a  typical  fibrinous  exudation,  or  it 
may  produce  suppuration  of  the  tissues.  Its  action,  even  in  producing 
suppuration,  is  not  circumscribed,  as  is  the  action  of  the  staphylococcus. 
Typical  suppuration  with  liquefaction  of  the  tissues  is  not  so  apt  to  be 
produced,  and  the  pus  has  not  the  thick  creamy  character  of  that  of  the 
staphylococcus.  In  many  cases  no  suppuration  at  all  is  produced,  but 
simply  an  infiltration  of  the  tissue  with  serum  and  leucocytes.  When 
suppuration  is  produced  by  the  streptococcus  ]\i/ogencs  it  usually  takes  the 
form  of  purulent  infiltration.  Strciptococci  may  be  found  in  the  tissues 
even  outside  of  the  line  of  leucocytes,  and  they  do  not  produce  so  much 
necrosis,  nor  do  they  themselves  exert  such  a  positive  chemotaxis,  as  do 
the  staphylococci.  Both  the  streptococci  and  staphylococci  may  produce 
on  serous  surfaces  extensive  suppuration.  On  both  serous  and  mucous 
surfaces  the  inflammation  produced  by  the  streptococci  is  accompanied 
by  a  greater  formation  of  fibrin.  The  inflammations  produced  by  the 
streptococci  are,  as  a  rule,  far  more  dangerous  in  their  local  and  in  their 
general  eflects  than  those  produced  by  the  staphylococci.  Inflammation 
of  the  uterus  in  puerperal  fever  is  almost  alwaj-s  due  to  the  action  of  the 
streptococci. 

Inflammations  produced  by  bacteria  show  in  one  way  a  vast  differ- 
ence from  those  produced  by  the  action  of  chemical  and  mechanical 
causes.  In  inflammation  produced  by  mechanical  causes  the  action  of 
the  cause  ceases  with  the  inflannnation.  It  is  impossible  that  it  should 
extend  to  other  parts  of  the  body.  Tlie  bacteria  may  be  in  various  wavs 
carried  from  one  portion  of  tiie  body  to  another,  and  wherever  they 

Vol..  I.— 12 


178  SURGICAL  PATHOLOGY. 

come  tliey  produce  tlie  same  character  of  inflammation  as  in  the  primary 
focus.  Those  inflammations  wiiich  apj)ear  in  the  dift'erent  portions  of 
tiie  body  following  a  primary  focus  of  inflammation  are  called  second- 
ary or  metastatic  inflammations.  The  organisms  may  jjass  along  the 
course  of  the  lymphatics,  either  producing  inflammations  in  places 
ooiniected  immediately  with  the  primary  focus  by  means  of  the  lym- 
pliatics,  as  the  lymphatic  glands,  or  they  may  be  carried  by  the  lymphatics 
into  the  blood  and  then  into  other  organs.  They  are  most  apt  to  be 
retained  in  the  nearest  lymphatic  glands  and  excite  these  to  inflamma- 
tion and  sui)paratit)n.  As  an  example  of  this  we  have  the  buboes  in 
the  groin  which  follow  local  processes  in  the  external  genitals.  The 
lymphatic  glands  may  also  be  excited  to  inflammation  by  other  products 
than  the  bacteria.  The  chemical  products  which  are  produced  in  the 
inflammatoiy  focus  are  washed  out  by  the  exudation  and  carried  by  the 
lymphatics  to  the  lymph-gland,  where  they  may  excite  inflammation. 
Such  inflammations  are  rarely  followed  by  suppuration,  anil  the  changes 
in  the  gland  more  generally  consist  in  hyperplasia  and  the  formation  of 
a  new  lymphoid  tissue. 

When  the  organisms  enter  into  the  blood  they  are  carried  into  all  of 
the  organs  and  tissues  of  the  body.  But  there  is  a  decided  difference  in 
their  action  in  the  different  tissues.  Certain  of  the  tis,sues  are  more 
lial>le  to  have  these  secondary  abscesses  following  on  blood-infection 
than  others.  When  the  staphylococcus  aureus  is  injected  into  the  ear- 
vein  of  a  rabbit,  the  metastatic  abscesses  take  ])lace  in  diflerent  organs. 
The  organisms  of  course  first  find  their  way  into  the  blood-vessels  of  the 
lungs,  but  here  it  is  extremely  rare  that  we  ever  find  any  lesions  pro- 
duced by  them.  The  secondary  foci  of  inflammation,  the  abscesses,  are 
generally  limited  to  the  kidney  and  to  the  myocardium.  They  may  also 
develop  in  the  muscles  of  the  body,  but  here,  again,  the  preference  is 
shown  for  certain  regions.  The  muscles  most  frequently  attacked  are 
the  abdominal  muscles.  It  is  difficult  to  explain  this.  The  frequency 
with  which  certain  organs  are  attacked  may  be  due  in  large  part  to 
special  diflerences  in  the  circulation  of  these  organs.  In  both  the 
kidney  and  the  heart  the  arteries  are  terminal ;  that  is,  each  porti(in 
of  the  tissue  is  snpjjlied  by  a  distinct  artery  without  anastomoses.  The 
same  condition  obtains  in  the  spleen  and  in  the  brain,  but  altscesses  only 
rarely  develop  in  these  parts.  It  cannot  be  due  to  the  greater  facility 
with  which  the  organisms  are  deposited  in  certain  organs.  All  sorts  of 
very  finely-divided  foreign  bodies  entering  into  the  blood  are  deposited 
with  greater  facility  in  the  liver  than  in  any  other  organ,  because  here 
there  is  an  enormous  system  of  cajiillaries  with  very  slow  circulation. 
It  is  probable  that  the  organisms  find  in  the  tissues  of  certain  organs 
more  favorable  conditions  for  development  than  in  others.  The  organ- 
isms appear  to  be  rarely  carrietl  as  large  embolic  masses  plugging  up 
blood-vessels.  In  the  kidney  there  is  little  doubt  but  that  they  do  act 
partly  in  this  way,  and  the  effect  of  their  sjiecific  presence  may  be  accom- 
panied by  the  mechanical  effects  of  infarction.  They  are  not  carried  as 
embolic  masses,  because,  even  if  they  were  injected  as  such  into  the 
veins,  they  would  not  be  able  to  pass  through  the  blood-vessels  of  the 
pulmonary  circulation.  In  the  kidney  their  action  has  been  closely 
studied  by  Ribbert.     It  is  probable  that  they  lodge  in  or  are  taken  up 


INFLAMMATION.  179 

at  some  point  in  the  circulation  by  the  endothelial  cells  of  the  small 
arteries,  and  by  their  continuous  growth  they  may  plug  up  the  vessel, 
and  from  this  primary  focus  they  may  be  carried  as  masses  into  smaller 
branches  of  the  same  artery. 

The  secondary  inflanuuation  may  be  pnjduced  in  another  way.  The 
bacteria  may  lind  entry  into  the  tissue  along  various  ducts  or  canals 
which  lead  from  the  j)rimary  focus  into  other  poi'tions  of  the  body. 
The  most  typical  example  of  this  is  given  in  the  secondary  abscesses 
which  develop  in  the  kidney  following  a  primary  purulent  inflammation 
of  the  bladder  or  of  the  urethra.  The  organisms  make  their  way  from 
the  bladder  into  the  kidney  in  a  direction  opposed  to  the  flow  of  the 
urine.  It  is  probable  that  their  progression  is  due  to  a  gradual  gi-owth 
along  the  wall  of  the  urethra  and  of  the  pelvis  of  the  kidney.  They 
may  do  this  without  producing  any  inflammation  of  the  urethra,  but 
most  often  there  is  a  general  inflammation  of  this ;  or  it  may  be  that 
they  find  suitable  conditions  for  growth  in  the  urine  in  the  urethra,  and 
infection  may  follow  in  this  way.  Rinne  includes  among  the  metastatic 
abscesses  those  produced  by  the  action  of  bacteria  which  enter  the  body 
without  producing  any  lesions  at  the  point  of  entry,  and  are  often  carried 
into  remote  organs,  where  their  action  takes  place. 

There  is  the  greatest  diversity  in  the  effects  produced  by  the  pyogenic 
organisms.  This  is  due  to  a  number  of  factors,  and,  although  much 
light  has  been  thrown  on  the  matter  by  experiments  on  animals,  there 
remains  much  which  is  not  at  all  or  imperfectly  understood.  As  a 
result  of  the  entry  of  the  same  organism  into  the  system  there  may  be 
no  effect  produced ;  or  there  may  be  a  slight  inflammation  not  leading  to 
suppuration  or  more  or  less  extensive  abscess-formation ;  or  without 
deflnite  abscess-formation  an  extensive  and  difi'use  purulent  infiltration 
of  the  connective  tissue;  or  without  the  production  of  any  local  lesions 
there  may  be  a  general  infection  of  the  blood,  and  death  may  take  place 
in  two  or  three  days  with  the  phenomena  of  an  acute  intoxication.  I 
saw  during  the  last  year  a  case  in  which  a  surgeon  died  several  days 
after  an  operation  on  a  case  of  peritonitis.  There  was  no  history  of  a 
wound  received  at  the  time  of  operation,  and  no  definite  point  of  entry 
for  the  organisms  could  be  found  at  the  autopsy.  The  most  extensive 
lesions  were  in  the  right  thigh  and  extended  from  this  up  to  the  buttocks. 
Over  these  parts  there  were  large  blebs  and  ])artial  desquamation  of  the 
epidermis.  The  subcutaneous  tissue  and  the  adjacent  muscles  Avere 
necrotic  and  contained  masses  of  streptococci.  The  same  organisms 
were  obtained  in  pure  culture  from  the  Idood  and  from  every  organ  of 
the  body.  The  infection  very  probably  took  place  from  the  thigh,  and 
the  organisms  possibly  entered  from  a  scratch  with  the  nail  or  in  some 
such  way.  There  was  no  definite  suppuration,  and  in  the  necrotic  tissue 
of  the  muscle  there  were  but  few  leucocytes. 

In  any  attempt  to  explain  such  variation  in  action  the  resistance  of 
the  tissue  must  he  considered.  This  resistance  is  due  to  a  number  of 
things.  The  blood-serum  is  directl)'  destructive  to  a  number  of  organ- 
isms, and  when  they  are  subjected  to  its  action,  in  some  cases  for  a 
few  hours  only,  they  are  destroyed.  Also,  there  is  no  doubt  that  the 
leucocytes  play  a  most  important  part  in  destroying  the  bacteria,  in  pre- 
venting their  absorption,  and  in  warding  off  their  action  from  the  sur- 


180  SURGICAL  rATHOLOar. 

rdiiiKlino;  tissue-cells.  It  is  probable  that  this  action  of  the  leucocytes 
is  not  the  only  way  that  tiie  body  has  ul"  combating  tlie  organisms,  but 
it  plays  an  important  part.  Ditiferent  animals  have  ditt'er(>nt  degrees  of 
susceptiljility  to  the  action  of  bacteria.  It  is  probable  that  this  is  largely 
due  to  differences  in  the  destructive  powers  of  their  serum.  The  number 
of  organisms  which  are  introduced  into  tlie  body  has  an  im])ortant  influ- 
ence. This  is  shown  by  the  results  of  the  injection  of  tiie  staphylo- 
coccus into  the  ear-vein  of  a  rabbit.  If  the  organisms  injected  are  of 
the  same  degree  of  virulence,  the  effect  produced  is  lai'gely  dependent 
upon  the  amount  of  the  culture  which  is  injected.  Very  small  doses 
may  produce  no  effects.  The  tissue  into  Mhicli  the  organisms  are  intro- 
duced is  of  importance.  After  the  injection  of  the  staphylococci  into 
the  car-vein  of  a  rabbit  abscesses  are  tlcveloped  in  certain  organs  only, 
and  this  cannot  be  explained  by  the  organisms  entering  these  organs 
only,  for  other  organs  are  equally  exposed  to  their  action.  The  same 
thing  is  seen  in  the  direct  injection  of  the  organisms  into  the  tissue.  The 
smallest  drop  of  a  pure  culture  of  the  staphylococcus  injected  into  the 
anterior  chamlier  of  the  eye  of  a  rabbit  is  sufficient  to  develo]i  an  exten- 
sive supjiuration,  with  loss  of  the  eye.  A  much  greater  quantity  is  neces- 
sary to  produce  an  abscess  when  the  injection  is  made  into  the  loose 
subcutaneous  tissue  of  the  back  than  is  required  when  the  injection  is 
made  into  the  dense  tissue  of  the  ear  or  into  the  muscles.  This  is 
probably  in  part  due  to  the  greater  ease  of  absorption  in  the  several 
places.  When  the  absorption  is  ra])id  the  bacteria  can  be  taken  into 
the  blood,  and  thci-e  be  destroyed  by  the  serum  without  time  being  given 
for  their  local  action  in  producing  necrosis  of  the  tissue  and  chemical 
poisons.  Grawitz  has  shown  the  importance  of  absorption  in  his  work 
on  the  production  of  peritonitis  in  the  dog.  This  animal  possesses  to  a 
high  degree  immunity  to  the  action  of  the  sta})hylococcus.  Large  quan- 
tities of  the  organisms  may  be  injected  into  the  peritoneal  cavity  with- 
out any  effect,  provided  the  tissues  are  normal.  If  the  po^^'er  of  al)sorp- 
tion  be  in  any  way  interfered  with,  or  if  the  serous  surface  be  stripped 
off  over  a  small  area,  general  purulent  peritonitis  results.  Halsted  has 
shown  that  the  same  thing  is  true  when,  instead  of  a  fluid  culture,  a 
piece  of  potato  with  a  growth  of  the  organism  on  its  surface  is  placed 
in  the  cavity.  In  this  case  a  fatal  peritonitis  is  always  produced.  The 
potato  has  nothing  to  do  with  the  result  beyond  affVjrding  a  suitable  ])lace 
for  the  development  of  the  organisms  and  allowing  them  to  produce  their 
chemical  poisons.  The  jjotato  without  the  organisms  becomes  rolled  up 
in  the  omentum  and  encaj^sulated.  If  an  emulsion  of  agar  with  the 
organisms  growing  in  it  be  injected  beneath  the  skin,  it  is  more  surely 
foli(>\\-ed  l)y  sujipuration  than  when  the  culture  is  injected  in  a  fluid 
medium.  One  of  the  main  elements  seems  to  be  the  action  of  the  sol- 
uble chemical  poisons  produced  by  the  organisms.  If  the  injection  is 
made  into  a  dense  tissue,  the  organisms  may  find  a  suitable  soil  for  their 
development,  or  they  may  create  it  by  the  production  of  necrosis  in  the 
surrounding  tissue.  The  poison  which  they  create  may  not  only  inhibit 
the  local  resistance  of  the  tissue,  but  when  it  is  gradually  absorbed  it 
may  destroy  the  germicidal  power  of  the  entire  blood-current.  In  any 
case  it  is  of  the  utmost  importance  to  oppose  to  the  action  of  bacteria 
as  normal  tissues  as  possible.     It  is  probable  that  a  great  deal  of  the 


INFLAMMA  TION.  1 8 1 

result  of  modern  methods  of  surgical  technique  is  due  as  much  to  the 
greater  care  bestowed  upon  wounds  as  to  the  care  exercised  in  excluding 
bajteria. 

Differences  in  the  virulence  of  the  organisms  play  an  imjiortant  jiart 
in  their  effects  on  the  tissues.  The  pus-organisms  are  not  definite  clicin- 
ical  conijiounds,  and  they  vary  enormously  in  their  virulence.  This 
virulence  is  gradually  lost  in  the  cultures.  It  remains  longer  in  the 
staphylococci  than  in  the  streptococci.  A  few  generations  of  cultures 
may  suffice  to  destroy  the  virulence  of  the  streptococci  completely.  In 
the  staphylococcus  aureus  we  can  to  some  extent  estimate  the  degree  of 
virulence  by  the  intensity  of  the  color  which  is  produced.  The  source 
from  wiiich  the  organisms  are  derived  is  also  of  importance,  as  is  also 
the  fact  whether  the  organisms  are  injected  alone  or  accompanied  with 
toxic  sulistanccs.  The  various  accompanying  toxic  substances  must  play 
a  great  part  in  the  purulent  infections  as  they  occur  under  natural  con- 
ditions. In  natui'al  infection  we  have  to  do,  not  with  pure  cultures 
of  the  pyogenic  cocci,  but  with  organisms  which  have  come  from  all 
sorts  of  sources  and  have  been  growing  in  various  conditions,  and 
which  are  frequently  mixed  with  many  kinds  of  bacteria.  There  is 
proof  that  under  some  of  these  conditions  the  infectious  material 
may  acquire  a  degree  of  virulence  Avhich  we  ai'e  not  familiar  with  in 
artificial  cultures.  Bumm  found  that  injection  into  the  peritoneal 
cavity  of  a  rabbit  of  a  fraction  of  a  drop  of  the  fluid  from  a  case  of 
acute  puerperal  peritonitis  produced  acute  peritonitis  in  the  animal, 
whereas  pure  cultures  of  the  same  organism  were  nothing  like  so 
virulent.  Fehleisen  found  that  a  pure  culture  of  the  staplti/Iococcus 
aureus  to  which  he  had  added  a  little  of  the  clear  fluid  from  the 
inflammatory  cedema  of  a  spreading  cellulitis  was  far  more  virulent 
than  the  ordinary  culture. 

Any  condition  of  the  system  which  lowers  its  general  resistance  will 
increase  the  action  of  the  pus-organisms.  It  has  been  found  that  sup- 
puration is  more  easily  excited  and  is  more  intense  in  animals  which 
have  been  rendered  aiifemic.  Even  when  local  ansemia  is  produced  by 
tying  or  constricting  an  artery,  the  suppuration  following  inoculation 
with  the  same  amounts  of  tlie  organisms  is  more  severe  on  the  anaemic 
side  than  on  tiie  normal.  If  the  blood  is  rendered  hydremic,  the  effects 
of  inoculation  ai'e  increased.' 

Some  of  the  infectious  diseases  render  the  tissues  more  liable  to  the 
effects  of  the  pyogenic  organisms.  This  has  been  shown  in  typhoid 
fever.  An  old  focus  of  inflammation  may  become  purulent  when  the 
resistance  of  tiie  tissues  is  lowered  by  disease.  Not  oidy  may  the  gen- 
eral resistance  of  th^  body  be  overcome,  but  the  local  resistance  as  \vell. 
Various  local  injuries  of  the  tissjes  have  been  produced,  and  then  organ- 
isms injected  into  the  circulation,  and  it  has  been  shown  that  in  many 
cases  the  organisms  have  settled  in  the  injured  tissues  and  have  there 
produced  a  purulent  inflammation.  Sometimes  the  presence  of  other 
bacteria  increases  the  action  of  the  pus-organisms.  Trombetta  lias 
sliown  that  when  cultures  of  the  staphylococcus  were  mixed  with  tiie 
prodigiosus  the  effects  were  increased.  The  tubercle  bacilli  and  the 
typhoid  and  other  organisms  when  mixed  with  the  staphylococci  have 

'  Welch  :  Conditions  underlying  the  infection  of  wounds. 


182  SURGICAL  PATHOLOGY. 

the  same  effect.  The  resistance  of  tlie  tissues  is  undoubteclly  lowered 
wlu'ii  cliemical  ])ro(lucts  of  tlie  liactcria  are  introduced  along-  with  tlicni. 
In  any  case  it  is  probable  tiiat  tlie  diminished  resistance  of  the  tissues  is 
due  to  changes  in  the  blood,  and  consists  chiefly  in  destruction  or  diminu- 
tion of  the  germicidal  power.  The  presence  of  such  chemical  products 
of  bacteria  may  also  prevent  the  establishment  of  leucocytosis.  While 
it  is  ]ir()bal)le  that  in  man  tlie  injection  of  even  a  large  number  of  pus- 
organisms  in  tile  normal  blood  would  have  little  or  no  effect,  the  con- 
dition is  different  when  the  organisms  enter  into  the  blood  after  its 
germicidal  jiower  has  been  weakened  by  absorption  of  poisons  from  the 
local  snpjiuration.  Metastatic  abscesses  do  not  develop  early  in  the  course 
of  a  suppuration,  but  at  a  late  period  when  the  blood  has  been  poisoned 
by  absorption.  They  are  not  due  alone  to  the  organisms.  Even  dead 
organisms  when  injected  into  the  tissues  in  sufficient  quantities  may 
excite  suppuration,  for  the  protoplasm  of  the  dead  bacteria  is  a  powerful 
agent  in  attracting  the  leucocytes. 

In  speaking  of  suppuration,  so  far,  we  have  only  considered  it  in 
relation  to  the  bacteria.  For  all  practical  purposes  that  is  the  only  way 
in  which  it  need  be  considered.  All  of  the  sujipuratlve  processes  whicli 
we  meet  with  in  man  are  due  to  bacteria,  and  they  may  be  obtained 
either  in  cultures  made  from  the  pus  or  on  microscopic  examination  of 
the  tissues.  If  the  cultures  made  from  an  abscess  are  sterile,  that  is  no 
proof  that  the  suppuration  was  not  produced  by  bacteria.  The  organisms 
may  be  dead  or  they  may  not  grow  on  the  medium  which  was  used  for 
culture.  Other  organisms  than  the  bacteria  may  excite  suppuration.  It 
is  known  that  some  of  the  protozoa  have  this  action.  The  amaha  coll 
when  it  enters  into  the  liver  from  the  large  intestine  will  produce 
abscesses,  and  it  has  been  found  to  be  the  cause  of  abscess-formation 
in  other  places.  Flexner  has  reported  a  case  in  whicli  an  abscess  of  the 
jaw  was  produced  by  this  organism. 

It  is  certain  that  typical  suppuration  may  be  produced  Ijy  chemical 
substances,  but  abscesses  so  produced  are  not  often  met  with.  There 
has  been  a  great  deal  of  experimenting  tlone  on  this  question,  and  it 
may  be  regarded  as  established  in  the  affirmative.  Croton  oil  is  one 
of  the  most  certain  substances  to  produce  suppuration  when  injected  into 
the  tissues.  In  a  series  of  experiments  croton  oil  was  enclosed  in  thin 
glass  capsules  which  were  pi'eviously  thorougldy  sterilized.  These  were 
placed  beneath  the  skin  of  rabliits,  and  after  several  days,  in  every  case 
after  the  wound  was  thoroughly  healed,  they  were  broken  from  without. 
In  every  case  a  typical  focus  of  supjiuration  was  produced.  It  has  long 
been  known  that  when  croton  oil  is  rubbed  into  the  skin  a  crop  of  small 
pustules  will  result.  Turpentine  and  a  few  other  substances  will  pro- 
duce supjiuration,  but  not  so  certainly  as  will  croton  oil.  There  is  no 
reason  why  some  of  these  substances  may  iKit  do  this.  They  are  caustics, 
and  when  they  come  in  contact  \\ith  the  tissues  they  will  produce  necro- 
sis ;  and  they  probably  have  in  themselves,  or  they  assist  in  forming  in 
the  tissues,  substances  which  have  the  power  of  dissolving  the  necrotic 
tissue  and  the  fibrin. 

Not  only  the  purulent  inflammations,  Ijut  inflammations  of  any  sort, 
are  affected  by  the  condition  of  the  liody,  and  especially  by  local  or  gen- 
eral pathological  conditions  of  the  cii\-iilation.     For  the  preservation  of 


IXFLAMMATWN.  183 

the  normal  coiKlition  of  tlie  tissues  a  normal  circulation  is  necessary.  The 
l^lootl  must  How  tlirougii  the  tissues  in  the  proper  amount,  with  the 
proper  pressure,  ?ind  the  quality  of  the  blood  must  not  be  altered.  A 
change  in  any  one  of  these  conditions  or  all  of  them  has  an  imjjortant 
influence  in  modifying  the  course  of  inflammation.  We  have  already 
spoken  somewhat  of  the  influence  of  auiemia  in  modifying  the  purulent 
inflanunation.  When  the  central  artery  of  the  ear  of  a  rabbit  is  ligated, 
sufficient  blood  will  enter  the  ear  by  the  small  arteries  on  the  edge  of 
the  ear  to  preserve  the  integrity  of  the  tissues.  If,  however,  after  liga- 
ting  the  central  artery  the  ear  be  exposed  to  influences  which  in  normal 
circidation  would  result  only  in  a  minor  degree  of  inflammation,  a  much 
more  severe  tvpe,  frequently  ending  in  necrosis  of  the  entire  tissue,  M'ill 
be  produced.  Samuel  has  sliown  tliat  tlie  exposure  of  the  ligated  ear  to 
water  at  a  temperature  which  would  only  slightly  atfect  the  part  in  a 
normal  circulation  will  be  followed  by  necrosis.  In  a  more  extensive 
series  of  experiments  in  parts  subjected  to  various  degrees  of  vascular 
disturbances  he  found  that  in  aufemic  parts  all  the  phenomena  of  inflam- 
mation developed  more  slowly  and  ran  their  course  in  a  much  longer 
time.  The  congestion  of  the  tissues  comes  on  more  slowly,  is  more 
extensive,  and  there  is  a  tendency  to  coagulation  of  the  blood  in  the 
dilated  vessels,  producing  complete  cessation  of  the  circulation. 

The  course  of  inflammation  is  also  modified  by  active  arterial  hyper- 
semia.  Danilewski  first  studied  this  by  exposing  both  ears  of  a  rabbit 
to  the  same  injurious  influence  after  section  of  the  sympathetic  on  one 
side.  He  found  there  was  a  marked  difference  in  the  course  of  inflam- 
mation in  the  hyperiBinic  ear  as  compared  with  the  other,  and  the  pro- 
cess took  a  more  rapid  and  ran  a  more  favorable  course.  He,  however, 
made  the  mistake  of  regarding  the  ear  not  operated  on  as  being  in  a 
normal  condition.  It  is  now  known  that  after  section  of  the  sympathetic 
the  hyperiemia  of  the  ear  on  the  side  which  is  cut  is  acconqianied  by 
anaemia  of  tlie  ear  on  the  uninjured  side  ;  so  that  he  really  compared 
inflammation  in  a  hyperKmic  part  witli  inflanunation  in  a  somewhat 
anaemic  part.  Samuel  afterward  studied  tlie  same  subject  more  carefully, 
and  found  that  in  a  hypercemic  part  a  more  severe  type  of  inflannnation 
followed  the  same  degree  of  injury  and  lasted  longer.  The  exudation 
is  more  abundant,  the  swelling  is  greater,  and  all  of  the  phenomena  are 
more  active.  After  the  inflannnatory  dilatation  of  the  artery  it  does 
not  so  quickly  return  to  the  normal  calibre  in  the  hypcra?mic  car  as 
in  the  normal. 

Still  more  unfavorable  are  the  conditions  when  inflammation  takes 
place  in  a  part  in  which  there  is  chronic  congestion.  Here  the  quantity 
of  the  blood  is  increased,  but,  owing  to  the  slowness  of  the  circulation, 
the  tissues  are  placed  in  an  abncrmal  condition.  The  part  can,  as  in  the 
anaemic  ])art,  preserve  its  integrity  under  tlie  ordinary  conditions  of  life, 
but  slight  influences  will  be  more  easily  felt.  The  blood  flows  nwre 
slowly  through  the  part,  the  blood-vessels  themselves  are  dilated,  and 
the  tissue  lives  on  a  lower  plane.  Its  reserve  force,  its  capacity  for 
rcjiair,  is  diminished.  Not  only  will  a  slight  cause  produce  a  more 
severe  type  of  inflammation,  but  tlie  inflammation  will  run  a  mucii 
longer  course  and  repair  take  place  more  slowly.  Inflammation  of  this 
character  is  spoken  of  as  hypostatic  inflammation,  and  a  good  example 


184  SURGICAL  PATHOLOGY. 

of"  it  is  seen  in  the  inflammation  of  the  posterior  part  of  the  hing  which 
comes  on  in  the  conrse  of  various  diseases  when  the  patient  iias  lain  for 
a  long  time  on  the  hac'iv.  The  ordinary  effects  of  liypostasis  in  such 
cases  are  increased  l)y  weakness  of  the  circulation  due  to  diminished 
force  of  the  heart's  contraction,  and  the  blood  itself  is  also  altered.  The 
cause  of  the  inflammation  in  such  cases  is  usually  the  stagnating  secretion 
of  the  bronchi,  in  which  infection  may  take  place. 

Another  example  is  seen  in  the  inflammation  of  the  leg  in  chi-onic 
jjassive  congestion  due  to  local  or  general  impairment  of  the  circulation. 
In  this  condition  a  slight  blow  or  other  form  of  injury  whicli  would  not 
be  felt,  or  only  slightly,  under  normal  conditions,  will  l)e  followed  by 
extensive  inflammation,  «hich  may  not  heal  until  the  part  be  placed  in  a 
condition  more  nearly  approaching  normal.  This  can  be  done  by  eleva- 
ting the  leg  and  removing  the  influence  of  gravity. 

Not  only  will  purulent  inflammation  take  place  more  readily,  but  any 
inflannnation  will  run  a  more  severe  course  in  a  person  wlio  is  the  sub- 
ject of  general  ana'mia.  Other  conditions — as  diabetes,  for  instance — 
have  a  marked  influence  on  inflammation.  In  diabetes  the  inflammation 
tends  to  assume  a  necrotic  character.  It  is  probable  that  in  diabetes  the 
germicidal  powers  of  the  blood-serum  are  greatly  diminished.  Infec- 
tion witli  the  pus-organisms  takes  place  more  readily  and  is  more  severe. 
The  primary  cause  of  inflannnation  being  injury  to  the  tissue,  however 
brought  about,  we  can  see  that  a  tissue  placed  in  an  abnormal  condition 
(•aunot  so  easily  guard  against  an  injury,  and  a  slight  cause  will  be  fol- 
lowed by  a  greater  effect.  The  inflammation  will  persist  until  the  integ- 
rity of  the  tissue  is  restored,  and  this  will  take  longer  when  the  condi- 
tions for  the  nntrition  of  the  tissues  are  not  so  favorable.  Sometimes 
a  tendency  to  certain  sorts  of  inflannnation  seems  to  be  inherited.  In 
some  persons,  even  when  the  circulation  and  nutrition  seem  to  be  pei- 
fectly  normal,  inflannnation  is  more  easily  excited  in  certain  organs 
and  takes  a  more  severe  course.  Thus  an  individual  may  be  predis- 
l)osed  to  inflammation  of  the  air-passages  and  other  parts  of  the  body. 
In  this  case  it  is  not  the  inflammation  itself  which  is  inlierited,  but  a 
weakness  or  lack  of  resistance  of  the  Ixidy.  AVhat  this  is  we  are  unal)le 
to  define.  It  may  be,  as  Cohnheim  suggests,  an  abnormal  condition  of 
the  blood-vessels  of  the  part.  It  seems  in  many  cases  to  be  local  and 
not  general.  In  some  cases  there  appears  to  be  a  general  weakness  of 
the  tissues  inherited.  There  may  be  an  inherited  lack  of  resistance  to 
certain  causes  of  inflammation  or  to  inflannnation  generally.  Individ- 
uals with  an  inherited  tendency  to  tuljereulosis  frequently  show  a 
general  lack  of  resistance  to  all  sorts  of  inflammatory  causes. 

Rejieated  attacks  of  inflammation  in  the  same  part  render  it  more 
liable  to  inflammation.  This  is  due  to  an  abnormal  condition  of  the 
part  caused  by  the  repeated  attacks  of  inflammation.  At  each  attack  of 
inflammation  the  tissue  may  not  be  completely  restored,  and  finally  an 
abnormal  tissue,  one  of  lower  resistance,  is  established.  The  tissue  is 
then  jjlaced  in  the  same  condition  as  when  subject  to  antemia  or  any 
other  disturbing  influence.  It  can  only  preserve  its  normal  condition 
under  ordinary  circumstances.  The  tissues  are  more  vulnerable,  and  a 
cause  which  would  not  be  felt  in  a  normal  tissue  may  produce  a  degree 
of  injury  in  this  ^vllicll  cannot  be  overcome  without  inflammation. 


IXFLA  .V.V.I  TIOX.  185 

It  is  not  necessary  to  consider  at  oreat  icnsith  the  diifercnces  between 
acute  and  clu'onic  intlamnuitiun.  The  phenomena  of  inflammation  vary 
in  duration  and  last  until  the  tissue  is  brought  to  a  normal  state.  In 
general,  the  difference  is  due  to  the  length  of  time  that  the  cause  of  inflam- 
mation continues.  A  sudden  injury  of  the  tissue,  in  which  the  cause  is 
rcmoyed  as  soon  as  tlic  injury  is  effected,  is  followed  by  active  inflam- 
matiiry  phenomena,  wliicli  will  also  sul)sidc  when  the  cause — that  is,  the 
injury  which  has  been  produced  on  the  tissues — is  removed.  In  some 
cases"  the  injury  may  take  place  more  slowly,  and  the  injurious  agent, 
whatever  its  character,  may  act  continously,  and  the  phenomena  of  inflam- 
mation develop  more  slowly  and  continue  for  a  longer  time.  In  those 
cases  we  have  the  process  of  repair,  the  attempt  o(  the  tissues  to  return 
to  a  normal  condition,  going  on  at  the  same  time  that  the  injurious  cause 
is  still  acting,  and  the  phenomena  wliich  we  are  accustomed  to  regard  as 
typical  of  inflammation — i.  e.  heat,  redness,  swelling,  and  pain — develop 
so  slowly  or  mav  be  so  slight  as  to  escape  our  attention  entirely.  These 
chronic  inflanmiations  are  frequently  due  to  bacteria,  which  may  extend 
their  action  not  only  to  the  tissues  into  which  they  first  enter,  but  may 
continously  affect  the  new  tissue  wiiich  is  produced  in  the  repair. 

Another  variety  of  inflannnation  is  the  so-called  tro])liic  inflammation 
suj>})osed  to  be  due  to  trophic  disturbances.  It  is  assumed  by  those 
believing  in  this  that  there  is  a  direct  nervous  influence  acting  on  the 
nutrition  of  the  tissues,  independent  of  the  influence  of  the  vasomotor 
ncryes.  The  nutrition  of  each  cell  is  sup])osed  to  be  directly  influenced 
l)v  the  nervous  system,  and  the  nerves  governing  this  nutrition  are  spoken 
of  as  trophic  nerves.  Physiologists  in  general  and  pathologists  do  not 
believe  much  in  this,  and  the  arguments  advanced  in  favor  of  the  view 
have  generally  come  from  clinicians.  As  an  example  of  such  so-called 
trophic  inflammations  we  may  cite  the  inflannnation  of  the  cornea  which 
follows  section  of  the  trigeminus.  INIagcndie  first  observed  that  after 
section  of  this  nerve  inflannnation  of  the  cornea,  with  ulceration  and 
<lestruction  of  the  entire  eye,  generally  takes  place.  Thei'c  may  also  be 
inflammation  of  the  lips  and  other  parts  supplied  by  this  nerve.  It  has 
been  also  observed  that  after  section  of  the  pneumogastric  pneumonia, 
fVer|uently  terminating  in  gangrene,  develops.  Another  example  of 
tropiiic  inflannnation  is  found  in  the  j)crfbrating  ulcer  of  the  foot  which 
develops  in  certain  diseases  of  the  s|)inal  cord.  In  most  cases  a  definite 
])roof  lias  been  given  by  experiments  that  these  inflammations  do  not 
take  place  when  other  injurious  influences  resulting  from  the  section  of 
the  nerve  are  excluded.  The  inflannnation  of  the  cornea  after  section  of 
the  trigeminus  is  the  result  of  the  action  of  particles  of  dust  and  other 
foreign  substances  which  the  eye  in  its  anresthetic  condition  is  no  longer 
able  to  guard  against.  It  is  possible  to  remove  the  eftect  of  the  action 
of  such  traumatic  influences  on  the  cornea  l)y  sewing  the  edges  of  the  lids 
together  or  by  fastening  one  of  the  animal's  ears  over  it.  Von  Gudden 
took  newly-born  rabbits  and  sewed  tlie  edges  of  the  lids  together,  pi'o- 
ducing  a  perfect  union.  After  the  wounds  were  healed  and  the  eyes 
absolutely  sealed  he  cut  the  nerves,  anil  on  0]3ening  the  eyes  fifteen  days 
after  the  nerve-section  he  invarialily  found  the  cornea  normal.  The 
inflammation  of  the  lungs  wiiicli  follows  section  of  the  pneumogastric  is 
due  to  the  presence  of  particles  of  fotxl  and  other  foreign  substances 


186  SURGICAL  PATHOLOGY. 

wliicli  linvc  been  aspirntcd  into  flic  hronclii.  Paralysis  of  the  jjlottis  is 
IH'odiiced  l)y  the  experiment,  and  tlic  mo.st  simple  way  of  preventinji; 
inflammation  is  to  lvee|)  the  animal  experimented  on  in  the  dorsal  position 
and  thus  ])revent  foreii;n  substances  ei)terin<;-  into  the  f^lottis.  8uch  lesions 
as  perforating  ulcer  of  the  foot  and  the  various  joint  diseases  which  occur 
in  the  course  of  certain  diseases  of  the  spinal  cord  are  extremely  rare  in 
patients  whose  circumstances  enable  them  to  avoid  over-exertion  in  the 
later  stages  of  the  disease  and  to  oI)serve  every  needed  care.  It  is  easv 
to  see  how  this  idea  of  trophic  iutlammation  may  have  arisen.  The 
tissues  are  placed  in  an  al)normal  condition.  Not  only  is  there  ana?sthesia 
of  the  tissue,  but  the  circulation  in  tiie  jjart  is  more  or  less  disturbed. 
Thus,  in  paralysis,  extensive  ulceration  (the  so-called  bed-sore)  is  fre- 
quently developed  over  the  sacrum  and  other  prominent  bony  eminences. 
This  is  due  to  a  variety  of  conditions — to  the  anaemia  which  is  produced 
Ijy  pressure  and  to  the  acti(jn  of  the  urine  and  fieces  which  are  frequently 
involuntarily  passed  by  the  patients,  and  unless  the  greatest  care  is  exer- 
cised the  parts  in  question  come  in  continuous  contact  with  them.  The 
epidermis  over  the  part  will  be  macerated  off,  and  the  tissue  beneath, 
whose  vitality  is  already  impaired,  will  be  exjiosed.  In  consequence  of  all 
of  these  conditions  the  tissue  becomes  necrotic  and  large  ulcers  will  form. 
Such  bed-sores  can  always  be  ])revented  by  proper  care  and  cleanliness, 
and  in  general  we  may  regard  them  as  due  not  to  trophic  disturljances, 
but  to  bad  nursing.  Cystitis  until  comparatively  recently  was  considered 
to  be  one  of  the  symptoms  of  inflammation  and  of  injury  to  the  spinal 
cord.  It  is  now  regarded  as  a  complication  easily  prevented  by  the  use 
of  clean  catheters  introduced  with  care. 

There  seems  to  be  much  more  proof  in  flivor  of  regarding  some  of  the 
herpetic  affections  as  due  to  trophic  influences.  These  develo])  in  the 
skin  over  the  area  supplied  by  certain  nerves,  and  it  has  been  found  in 
some  cases  that  the  nerves  or  the  ganglia  from  which  they  arise  are 
inflamed.  Samuel  suggests  the  jiossibility  that  these  inflammations  may 
be  due  to  an  intense  hyper:emia  of  the  part  brought  about  by  the  paralysis 
of  the  vasomotor  nerves.  Striim])el  suggests  the  probability  that  the 
inflannnation  in  herpes  zoster  may  be  infectious  and  due  to  a  definite 
cause.  One  argument  in  favor  of  this  is  the  frequent  appearance  of 
herpes  zoster  in  an  epidemic  or  endemic  form.  Pfeiffer  thinks  that  in 
these  eases  the  inflammation  should  be  regarded  as  an  infection  which 
follows  along  the  course  of  the  intercostal  nerves.  The  nutrition  of 
parts  is  undoulitedly  affected  by  nerN'ous  influences,  and  integrity  of  the 
nerves  is  necessary  to  keep  the  tissue  in  a  normal  condition.  No  part 
receives  continually  the  same  supply  of  blood,  but  the  blood-supply  is 
regulated  according  to  the  needs  of  the  tissue  by  the  vasomotor  nerves. 
When  action  of  these  nerves  is  destroyed  the  part  is  simply  placed  in  an 
abnormal  condition  as  regards  its  nutrition,  and  injuries  are  more  easily 
produced  and  less  easily  repaired. 

A  peculiar  variety  of  inflannnation  is  that  known  as  sympathetic 
inflannnation.  Certain  organs  of  the  body  stand  in  a  particularly  close 
relation  with  one  another,  and  inflammation  of  one  is  followed  by  inflam- 
mation of  the  other.  The  best  example  of  this  is  given  in  the  infectious 
parotiditis,  or  mumps.  In  this  tiie  acute  inflammation  of  the  parotid 
gland  is  frequently  followed  in  the  male  by  inflammation  of  the  testicles. 


ULCERATION.  187 

Avhich  often  reaches  a  severe  deojree,  and  in  the  female  by  a  similar 
inflammation  of  the  mammary  glands  and  ovaries.  The  cause  of  this  is 
absolutely  unknown.  It  may  be  that  the  infectious  agent,  •whatever  its 
nature,  which  causes  the  inflammation  of  the  parotid  is  localized  in  the 
other  organs,  or  it  may  be  that  the  chemical  products  which  are  ])roduced 
in  the  inflammation  of  the  parotid  gland  have  a  special  pathogenic  influence 
on  other  parts  of  the  body.  The  fact  that  the  inflammation  of  the  other 
parts  does  not  usually  take  ])lace  simultaneously  with  that  of  the  parotid, 
but  at  a  later  stage  of  the  disease,  would  seem  to  be  in  fiivor  of  the  latter 
theory.  There  is  certainly  no  direct  nervous  or  vascular  connection  between 
the  glands.  It  is  only  the  specific  infectious  parotiditis  which  is  followed 
by  these  sympathetic  inflammations.  Abscesses  of  the  parotid  due  to  the 
entry  of  bacteria  into  the  gland  along  the  duct  are  not  followed  by  sym- 
pathetic inflammations.  Another  example  of  the  sympathetic  inflamma- 
tion is  the  inflammation  of  one  eye  which  follows  inflammation  of  the 
other.  It  is  only  when  inflammation  afl'ects  certain  parts  of  the  eye  that 
the  other  eye  is  apt  to  become  attected.  Inflammation  of  the  conjunctiva 
or  of  the  cornea  is  not  followed  l)y  any  affection  of  the  other  eye.  It  is 
only  when  the  inflammation  aflects  the  iris  and  the  deeper  parts  of  the 
eye  suj)plied  liy  the  sympathetic  nerves  that  inflammation  of  the  other  eye 
takes  place.  Deutschman,  who  has  investigated  the  subject  by  inoculating 
one  eye  with  various  bacteria,  has  thought  that  he  could  follow  the  course 
of  the  inflammation  along  the  optic  nerve  to  the  chiasm,  and  then  to  the 
other  eye.  He  supposes  that  it  is  due  to  bacteria  \\hich  take  this  route. 
His  experiments  have  been  carefully  repeated  by  Randolph  at  the  Johns 
Hopkins  Hospital  with  negative  results.  Against  the  view  of  Deutsch- 
man that  the  affection  of  the  uninjured  eye  is  due  to  bacteria  is  the  fact 
that  the  specific  infections  of  one  eye  are  not  folloM'cd  by  similar  affections 
of  tlie  other.  Thus  tuberculosis  of  the  iris  and  of  the  other  parts  of  the 
eye  may  destroy  one  eye  without  producing  any  lesions  whatever  in  the 
other.  As  a  rule,  it  is  only  acute  suppurative  inflammations  which  tend 
to  extend  in  this  way.  It  is  possible  that  the  inflammation  may  be  due 
to  the  action  of  specific  chemical  substances  produced  in  the  inflamed  eye 
on  the  other.  The  M'hole  question  of  sympathetic  inflammation,  how- 
ever, is  still  very  obscure. 

Ulceration. 

An  ulcer  is  a  loss  of  substance  on  a  surface  of  the  body.  Ulceration 
is  very  closely  connected  with  inflammation,  and  is  frequently  due  to 
this.  The  ulcer  really  represents  a  part  of  an  abscess-wall.  If  an 
abscess  is  seated  in  tlie  sultcutancons  tissue  and  opens  on  the  skin,  there 
may  be  continuous  inflammation  and  suppuration  along  the  canal  which 
leads  to  the  abscess-cavity,  and  in  this  way  fistulas  are  formed.  The  wall 
of  the  fistula  leading  to  the  old  abscess  has  the  same  membrane  which  is 
found  in  the  abscess  itself.  When  the  abscess  is  superficial,  and  when 
the  opening  is  almost  as  large  as  the  aljscess  itself,  we  do  not  speak  of 
it  as  a  fistula,  but  the  opening  together  with  the  abscess  is  spoken  of  as 
an  ulcer.  In  the  ulcer  there  is  always  a  loss  of  substance,  ex])osing  the 
deeper  parts  of  the  tissue  unprotected  by  epidermis,  and  a  chronic 
inflammation   of   these  deeper  parts.      The  ulcer  ordinarily  arises  in 


188 


SURGICAL  PATHOLOGY. 


consequence  of  inflammiitiou  or  injury  wliifli  destroys  the  ])rotec- 
tive  surface  and  lays  bare  the  tissiu's  heucatli.  The  base  and  edges 
of  the  ulcer  have  the  properties  of  iuHanuuatory  tissue,  and  in  their 
structure  arc  similar  to  tissue  which  lines  the  wall  of  an  abscess.  The 
base  of  an  ulcer,  as  a  rule,  is  co^•ered  with  a  soft  reddish  tissue  w^ith 
an  uneven  surface.  Often  the  surface  is  covered  with  small  eleva- 
tions varying  in  size,  which  give  it  a  granular  appearance,  and  the 
small  elevations  are  called  granulations.  The  tissue  of  which  the 
base  of  the  ulcer  is  composed  has  received  in  consequence  the  name 
of  granulatit)n  tissue,  and  the  name  has  been  extended  to  all  similar 
tissues  even  when  there  are  no  granulations  present  (Fig.  7).    The  gran- 

Fio.  7. 


Dense  cicatricial  tissue  at  the  bottom  of  an  old  ulcer  of  the  le^.    The  blood-vessels  are  numer- 
ous, but  are  compressed  by  the  surrounding  tissue. 

ulations  are  simply  the  small  elevations.  The  same  sort  of  tissue  is 
found  in  all  sorts  of  chronic  inflanniiations,  and  the  name  has  been 
extended  to  characterize  a  group  of  tumors  closely  related  to  intlam- 
mation  which  have  received  the  name  of  granulomata,  because  their 
tissue  is  similar  to  the  tissue  found  in  the  granulations  of  an  ulcer. 
These  granulations  appear  to  be  composed  of  projecting  masses  of 
blood-vessels  with  newly-formed  tissue  around  them.  Sometimes  the 
grantdations  are  exceedingly  well  marked,  in  other  cases  not.  They 
are  in  general  best  seen  in  ulcers  of  the  skin.  They  are  not  pres- 
ent, to  any  extent  at  least,  in  ulcers  formed  in  the  alimentary  canal, 


ULCERATION.  189 

and  a  deep-seated  abscess-cavity  does  not  contain  them.  Hamilton 
has  advanced  u  rather  ingenious  explanation  for  the  formation  of 
these  granulations :  It  is  known  that  all  liipiids  and  tissues  of  the 
body  are  under  a  ceitain  pressure,  and  the  force  exerted  in  the  dis- 
tention of  the  blood-vessels  by  the  heart  is  opposed  by  the  elasticity  of 
the  tissue  around  the  vessels,  which  prevents  any  marked  degree  of 
dilatation.  All  the  so-called  cavities  of  the  body,  such  as  the  peri- 
toneum, pleura,  and  pericardium,  have  their  surfaces  in  accurate  ap- 
position or  are  filled  with  some  resisting  material  which  counter- 
balances the  pressure  of  the  blood.  If  an  inflammatory  exudation 
takes  place  between  the  siu-faces  of  the  pericardium,  the  pleura,  or  the 
peritoneum,  the  transudation  of  fluid  into  the  cavity  goes  on  until 
the  pressure  ui  the  cavity  becomes  ecpial  to  that  of  the  blood-vessels 
in  the  walls.  Hamilton  supposes  that  the  granulations  are  formed  by 
the  dilatation  of  the  blood-vessels  and  their  extension  ujjward  toward 
the  surface,  where  they  are  not  opposed  by  the  pressure  of  the  tissue 
over  them.  In  this  way,  by  tlie  longitudinal  extension  of  tlie  vessels, 
projecting  loops  would  be  formed.  It  is  very  probable  that  this  lack  of 
pressure  of  the  surrounding  parts  has  much  to  do  with  the  dilatation 
of  the  blood-vessels  which  is  found  in  a  granulating  surface  and  the 
slow  movement  of  the  blood  in  the  vessels.  The  effect  of  removal  of 
pressure  is  almost  the  same  as  would  be  jiroduced  by  placing  the  entire 
hand  in  a  vessel  froni  which  the  air  is  exhausted.  All  of  tlie  blood-ves- 
sels would  become  more  or  less  dilated,  and  there  would  be  an  increased 
difficulty  for  the  passage  of  blood  from  the  part,  while  the  flow  of  blood 
to  the  pai't  would  be  greatly  accelerated  and  the  transudation  of  fluid 
greatly  increased.  It  is  not  probable  that  Hamilton  is  right  in  consider- 
ing that  the  granulations  on  the  surface  of  a  cutaneous  ulcer  are  due 
solely  to  tlie  action  of  these  influences  on  the  normal  blood-vessels, 
because  there  are  no  such  groups  of  blood-vessels  in  the  skin  to  which 
these  granulations  could  conform.  ,  It  is  23rol)able,  however,  that  the 
absence  of  pressure  has  something  to  do  with  it. 

The  ulcer  represents  the  best  type  of  a  chronic  inflammation.  The 
tissue  is  deprived  of  its  ]iroteeting  epidermis,  and  is  subject  to  a  contin- 
uous injury  which  will  ])crsist  until  the  covering  of  epidermis  is  again 
restored.  Tlie  tissue  is  not  only  subjected  to  the  constant  action  of  irri- 
tating substances,  but  also  to  drying.  On  the  surface  of  the  ulcer  there 
is  always  a  more  or  less  superficial  layer  of  necrosis.  In  the  necrotic 
tissue  and  immediately  below  it  there  will  be  a  variable  luunber  of  pus- 
cells.  Tliese  come  not  only  from  the  normal  blood-vessels  of  the  part, 
but  the  emigration  also  takes  place  in  the  same  way  from  the  blood-ves- 
sels of  the  granulation  tissue.  The  granulation  tissue  covers  the  entire 
base  of  the  ulcer  and  extends  to  a  variable  depth  in  the  tissue  beneath. 
In  places  this  extension  into  the  deeper  tissues  is  much  more  marked 
than  in  others.  The  granulation  tissue  is  comj)osed  of  small  round  cells 
closely  ])acked  together,  with  very  little  intercellular  substance.  On 
shaking  tlic  cells  from  a  thin  section  little  or  no  fibrilla-connective  tis- 
sue is  found  l)ctween  tlie  cells,  but  the  cells  are  held  together  by  a 
mucoitl  substanc'c.  Blood-vessels  are  extremely  numerous  in  these 
granulations.  They  are  dilated,  the  blood  flows  in  them  with  com- 
pai'ative  slowness,  and,   in  spite  of  the  number  of  blood-vessels,  it  is 


190  SURGICAL  PATIIOLOOY. 

})r()bable  that  less  blood  fldws  into  the  part,  f<jr  tlio  siipjjly  of  the  large 
vascular  area  of  the  granulation  \X'ssels  is  frecj[uently  only  a  small  artery. 

Repair  of  Inflammation. 

When  the  cause  of  the  inflaniniation  is  temporary  the  inflamed  part 
returns  very  quickly  to  a  normal  eonditiwi.  The  vessels  return  to  their 
normal  calibre,  the  leucocytes  cease  to  accunuilate  in  the  periphery  and  to 
emigrate,  and  the  stagnation  of  the  blood  in  the  dilated  vessels  passes 
away.  This  may  take  place  before  any  exudation  has  been  formed. 
When  exudation  has  taken  place,  this  may  not  disappear,  and  the 
inflamed  part  cannot  return  to  its  normal  condition  because  the  presence 
of  the  exudation  itself  produces  more  or  less  injury  to  the  tissue,  atfect- 
ing  its  nutrition  in  various  ways  and  acting  as  a  cause  of  inflammation. 
There  is  no  difficulty  in  the  remo\'al  of  the  fluid  portion  of  the  exuda- 
tion. It  is  simply  taken  up  and  absorbed  by  the  lymphatics  of  the 
part — a  certain  amount  of  it  also  by  the  veins.  Even  while  the  exuda- 
tion is  taking  place  there  is  increased  absorption  of  the  fluid,  and  an 
inflammatory  oedema  or  a  serous  exudation  soon  disappears  \\hen  the  cause 
producing  it  has  disappeared,  and  no  new  exudation  takes  place.  Even 
the  corpuscular  elements  of  the  exudation,  and  the  fibrin  as  long  as  it  is 
present  in  only  slight  amounts,  may  disappear.  The  colorless  corpuscles 
can  be  removed  in  the  same  way  as  the  fluids.  They  can  enter  directly 
into  the  lymphatics.  The  few  red  corpuscles  in  the  exudatic)n  gradually 
lose  their  coloring  material  and  are  dissolved,  and  even  the  fibrin  itself 
becomes  changed  into  a  granular  emulsion  which  is  taken  up  by  the 
lymphatics.  These  simple  processes  of  restoration  are  much  more  diffi- 
cult when  the  mass  of  the  exudation  is  very  considerable,  as  in  a  large 
pleuritic  exudation,  an  extensive  pneumonia,  or  an  extensive  purulent 
inflammation.  A  large  exudation  may  even  oppose  mechanical  diffi- 
culties in  the  way  of  restoration  of  the  integrity  of  the  tissues.  The 
absorption  of  these  large  exudations  makes  great  demands  on  the  func- 
tions of  the  lymphatics,  especially  in  individuals  in  whom  the  force  of 
the  blood-  and  Ij'mph-circulation  has  been  weakened  by  inflammation. 
In  any  case  the  restoration  nuist  take  place  very  slowly,  and  it  is  better 
to  shorten  the  process  of  absorption  whenever  it  is  possible  by  artificial 
removal  of  the  exudation.  The  blood-vessels  may  be  compressed  by 
the  exudation,  and  the  active  circulation  of  blood  in  them  necessary 
for  absorption  may  be  prevented.  When  an  exudation  is  solid,  being 
composed  principally  of  leucocytes  and  fibrin,  it  must  become  in  a 
measure  liquefied  before  absorption  can  take  place.  In  acute  croupous 
pneumonia  the  exudation  in  the  air-cells  in  consequence  of  fatty  degen- 
eration becomes  converted  into  an  emulsion,  which  can  then  be  absorbed 
by  the  lymphatics  and  blood-vessels  of  tlie  lung  or  can  pass  into  the 
bronchi  and  be  so  removed.  It  is  evident  that  the  richer  the  exudation 
is  in  solid  elements,  the  slower  it  will  be  absorbed,  and  this  holds  espe- 
cially for  exudations  composed  of  pus-cells.  In  this  the  reason  for 
artificial  i-emoval  is  still  more  forcible,  because  not  only  is  the  absorption 
of  such  an  exudation  more  difficult,  Init  as  long  as  the  exudation  con- 
tinues, containing  as  it  does  tiie  bacteria  which  produce  it,  it  acts  as  a 
further  cause  for  inflammation. 


REPAIR  AND  REOENERATION. 


191 


When  not  removed  the  exudation  may  become  changed  into  a  yellow- 
ish-white, more  or  less  dry  mass  of  about  the  consistency  of  cheese.  This 
is  spoken  of  as  the  caseation  of  the  exudation.  It  takes  place  preferably 
in  those  exudations  due  to  definite  causes,  as  in  tuberculosis  and  syphilis, 
but  it  is  not  exclusively  confined  to  these.  Lime-salts  may  be  deposited 
in  this  dry  necrotic  tissue,  and  it  can  be  converted  into  a  solid  or  gritty 
calcareous  mass  which  must  always  remain  in  the  tissue.  It  acts  here 
as  a  foreign  body,  and,  as  other  foreign  bodies,  it  will  continue  to  excite 
infiannnation  around  it. 

When  the  exudation  disappears  by  simple  absorption  by  the  blood- 
vessels of  the  part,  it  is  spoken  of  as  resolution.  In  many  cases  the 
normal  circulation  of  a  part  will  not  be  sufficient  to  effect  the  removal 
of  the  exudation,  and  new  tissue  and  new  blood-vessels  must  be  formed 
before  the  exudation  can  be  removed.  This  is  spoken  of  as  the  organiza- 
tion of  the  exudation :  it  is  seen  best  on  serous  surfaces.     When  there 


Fig.  8. 


Formation  of  connective  tissue  in  blood-clot.  (The  specimen  was  obtained  from  Dr.  Halstead.) 
The  clot  first  becomes  infiltrated  with  Ic  icocytes,  and  formation  of  tissue  takes  place,  proceed- 
ing from  the  deeper  tissue:  a,  young  connective-tissue  corpuscles;  b,  leucocytes;  c,  uewlv- 
lormed  blood-vessel. 

is  on  the  surface  of  the  pleura  a  fibrinous  exudation  which  reaches  any 
considerable  extent,  it  becomes  organized.  Beneath  the  exudation  there 
is  a  regenerative  new  formation  of  ti.ssue  which  takes  place  from  the 
normal  tissues.  In  this  a  tissue  similar  to  the  granulation  tissue  at  the 
base  of  the  ulcer  is  formed.     New  blood-vessels  are  developed  in  this, 


192  SURGICAL  PArilOLOGY. 

whicli  project  upward  into  the  fibrin.  The  formation  of  granulation 
tissue  continues  along  these  blood-vessels,  and  tinally  a  young  connective 
tissue  is  formed,  the  exudation  disappearing  as  this  takes  its  place  (Fig.  8). 
In  cases  of  inflammation  of  serous  surfaces  tlie  same  cause  which  pro- 
duces the  inflammation  on  one  surface  will  act  in  producing  an  inflam- 
mation on  the  surface  which  it  touches.  When  organization  takes  place 
a  direct  union  by  means  of  young  connective  tissue  is  formed  betM'een 
the  two  surfaces,  and  produces  adhesions  which  may  give  more  or  less 
trouble  in  after  life.  The  adhesions  which  are  so  frequently  found 
between  the  visceral  and  parietal  i)leural  surfaces  are  due  to  a  preceding 
inflammation,  which  may  have  been  of  such  a  slight  character  as  to  have 
given  rise  to  no  symptoms  and  not  to  have  been  recognized  during  life. 
The  exudation  may  in  every  place  undergo  organization  ;  even  in  acute 
croupous  pneumonia  the  exudation  within  the  air-cells  of  the  lung  may 
in  certain  cases  undergo  organization  in  the  same  manner  as  tlie  exuda- 
tion on  a  serous  surface,  and  there  \\ill  always  remain  in  the  alveoli  of 
the  lung  the  newly-formed  connective  tissue.  In  inflammation  which 
takes  place  in  the  parenchyma  of  organs  the  exudation  may  be  in  part 
removed  in  the  same  way,  and  a  new  tissue  be  formed  which  will  not 
completely  disappear.  A  certain  amount  of  this  new  formation  of 
tissue  takes  place  in  nearly  all  inflanunations,  and  its  presence  may 
serve  to  indicate  a  preceding  inflammation  even  when  the  exudation  has 
disappeared. 

In  the  repair  of  inflammation,  in  the  restoration  of  the  tissues  to 
their  normal  integrity,  not  only  must  the  exudation  be  removed,  but 
the  injury  of  the  tissue  which  has  been  the  cause  of  the  inflannnation 
in  the  first  place  must  be  repaired.  In  any  inflammation  there  is  always 
a  destruction  of  tissue,  and  the  tissue  destroyed  must  be  replaced  by 
a  new  formation  of  tissue.  This  begins  early,  and  may  be  seen  while 
the  inflammation  is  advancing.  The  new  formation  of  tissue  may  be 
better  studied  in  slight  injuries  of  the  cornea  than  elsewhei'e,  and  liere 
the  two  processes,  the  vascular  phenomena  with  the  formation  of  the 
exudation  and  the  new  production  of  tissue,  can  be  considered  separately. 
When  the  loss  of  tissue  is  very  slight,  and  when  the  action  of  the  injury 
which  caused  it  subsides  at  once,  inflammator}'  phenomena  M'itli  exuda- 
tion and  emigration  do  not  necessarily  take  place.  In  the  ordinary 
physiological  processes  of  life,  and  in  all  tissues,  there  is  constantly 
taking  place  a  loss  of  material  which  is  supplied  without  any  inflam- 
matory phenomena.  The  power  of  the  tissue  to  sujjply  a  loss  is  greater 
than  is  ordinarily  called  for,  just  as  in  the  circulation  there  is  a  reserved 
force  in  the  power  of  the  heart  which  can  meet  all  ordinary  conditions 
called  for,  and  even  extraordinary  conditions,  by  an  increased  muscular 
action.  In  all  the  tissues  of  the  body  there  is  a  greater  power  of  repair 
than  is  ordinarily  called  for.  But  in  the  tissues,  as  in  the  circulation, 
this  reserve  force  has  its  limit.  The  destruction  of  any  considerable 
amount  of  tissue  is  always  followed  by  inflammation.  Even  when  the 
cause  which  produces  the  injury  subsides  at  once,  still  the  injured  tissue 
itself  will  act  as  a  sufficieut  cause.  When  a  cornea  is  touched  with  the 
end  of  a  thread  saturated  with  sulphate  of  zinc,  a  very  limited  injury 
will  be  produced.  This  is  followed  by  a  new  formation  of  cells  in  the 
territory  immediately  around  the  injury,  to  take  the  place  of  the  cells 


REPAIR  ASD  REGENERATION.  193 

which  liave  been  destroyed.  Tliis  new  formation  of  cells  begins  forty- 
eigiit  hours  after  the  injury,  and  the  same  phenomena  of  cell-division 
take  phice  that  we  find  in  eell-di vision  anywiiere.  The  nuclei  nf  tlie 
cells  divide  by  karyokinesis.  Long  processes  are  formed  which  extend 
up  into  the  neci'otic  tissue,  and  the  nuclei  from  the  old  cells  travel  up 
into  these.  In  many  cases  there  seems  to  be  a  difference  in  the  regen- 
eration of  tissue,  depending  upon  the  degree  of  destruction.  In  the 
minor  degrees  of  injury,  where  only  the  cells  themselves  are  destroyed, 
there  is  simply  a  new  formation  of  cells  having  the  same  <'haraeter 
as  the  old,  witiiout  any  intermediate  stages.  In  one  point  the  jiatiio- 
k)>jical  rcoeneration  of  tissue  differs  materiallv  from  the  ph\siolo"ical. 
It  is  frequently  not  confined  to  a  simple  restoration  of  the  tissue  lost, 
but  the  amount  jJi'oduced  widely  exceeds  this.  In  inflammation  of  the 
skin  there  is  often  an  excessive  epithelial  growth,  and  scars  may  be 
]irodaced  from  the  connective-tissue  regeneration  which  at  first  pro- 
ject beyond  the  level  of  the  skin  and  appear  as  red  elevations.  In  the 
inflammatory  regeneration  of  bone  more  callus  is  produced  than  is  neces- 
siiry  for  the  supply  of  the  portions  of  bone  which  have  been  lost.  The 
power  of  regeneration  is  different  not  only  in  the  different  tissues  of 
the  body,  but  also  in  different  animals.  The  higher  the  organization  and 
the  greater  the  differentiation  of  tissue,  the  less  is  the  power  of  regen- 
eration, which  is  greater  the  younger  the  animal  and  tlie  nearer  it  comes 
to  an  emljryt)nic  ccmdition.  In  some  of  the  lower  animals,  as  the  Crus- 
tacea, an  entire  part  may  be  removed,  and  it  may  be  completely  re-formed. 
In  the  frog  the  power  of  regeneration  is  much  more  marked  in  the  tad- 
pole than  in  the  adult.  When  the  tail  of  the  tadjiole  is  removed  an 
entire  new  production  of  tissue  will  take  place.  The  different  tissues 
also  show  different  powers  of  regeneration  after  loss.  The  more  C(im- 
pletely  diflerentiated  the  tissue  and  the  farther  it  is  removed  from  an  em- 
bryonic condition,  the  less  is  the  power  of  regeneration.  In  some  tissues 
it  is  probable  that  there  is  no  new  formation  of  cells,  and  only  the 
portions  of  the  cells  which  have  l)e(>n  used  u])  by  tlie  physiological  ])ro- 
cesses  will  be  restored.  After  injury  in  the  central  nervous  svstem  there 
is  no  new  formation  of  nerve-cells.  The  same  thing  is  true  to  a  more 
limited  extent  in  the  striated  muscles.  Any  loss  in  these  tissues  is  sup- 
plied by  a  gro^vth  of  connective-tissue  elements.  In  certain  of  the 
glandular  organs  the  power  of  regeneration  is  greatly  limited. 

The  new  formaticjn  of  connective  tissue  in  inflammation  does  not 
always  take  the  form  of  a  pure  regeneration.  In  the  place  of  the  nor- 
mal connective  tissue  a  somewhat  different  tissue  is  formed,  which  is 
designated  as  cicatricial  tissue.  This  cicatricial  tissue  differs  from  the 
normal  connective  tissue  in  the  paucity  of  its  cells  and  blood-vessels 
and  in  the  density  of  .its  intercellular  substance  (Fig.  7).  The  charac- 
ter of  the  intercellular  substance  seems  to  be  similar  in  general  to  white 
fibrous  tissue,  but  its  exact  character  has  never  been  fully  made  out. 
The  fihrillie  are  more  firmly  interwoven  together,  and  cannot  be  sepa- 
rated so  easily  as  they  can  in  white  fibrous  tissue.  In  some  inflammations, 
especially  in  the  more  chronic,  the  new  formation  of  connective  tissue 
may  so  greatly  exceed  the  necessary  amount  to  su])ply  the  defect,  and 
form  so  ])rominent  a  part  of  the  inflammatory  process,  that  inflamma- 
tions of  this  character  have  received  a  different  name  and  are  known  as 

Vol.  I.— 13 


194  SURGICAL  PATHOLOGY. 

productive  inflammations.  The  excessive  amount  of  connective  tissue 
wliich  is  formed  may  often  exert  a  deleterious  influence  ou  the  future 
life  and  the  functions  of  the  inflamed  part. 

In  order  tliat  any  new  formation  of  tissue  may  take  place  new  blood- 
vessels are  necessary.  TJie  okl  l)lood-vessels  of  the  part  wiiere  tiie  new 
tissue  is  to  be  formed  have  been  destroyed  to  a  great  extent,  and  multi- 
plication of  cells  will  not  take  place  except  under  tlic  Ijest  conditions  of 
nutrition.  If  I'cgeneration  to  any  extent  takes  place  in  non-vascular 
parts,  these  become  vascular.  In  any  extensive  injury  of  the  cornea 
new  blood-vessels  grow  into  the  tissue  from  the  sclera  in  a  comparatively 
short  time.  In  man  ulceration  of  the  cornea  is  always  followed  by  a 
vascularization  of  the  portion  of  the  cornea  between  the  ulcer  and  the 
sclera.  These  new  blood-vessels  are  formed  from  the  old.  The  for- 
mation takes  place  by  direct  outgrowth  from  the  old  vessels.  In  this 
formation  both  tiie  endothelium  of  the  vessels  and  the  connective-tissue 
cells  in  the  neighborhood  of  the  vessels  take  part.  The  process  is  the 
same  as  in  the  new  formation  of  blood-vessels  in  the  embryo.  It  can 
be  well  studied  in  the  regeneration  of  tissue  which  takes  place  after  cut- 
ting otf  the  end  of  a  tadpole's  tail.  The  first  thing  which  seems  to  take 
place  is  an  enlargement  of  the  endothelial  cells  of  tiie  vessels.  These 
become  large,  filled  with  protoplasm,  and  long  projections  extend  into 
the  neighl)oring  tissue.  The  nucleus  of  the  cells  divides,  and  nuclei 
pass  up  into  the  projection  in  very  nuich  the  same  way  as  in  the  regen- 
eration of  the  cells  of  the  cornea.  Tlie  connective-tissue  cells  in  the 
vicinity  enlarge,  and  arrange  themselves  cither  alongside  of  the  projec- 
tion from  the  endothelium  or  as  a  continuation  of  this.  In  this  way 
pointed  processes  of  some  length  are  formed.  These  meet  with  similar 
processes  from  the  same  vessel  or  from  neighboring  vessels,  and  in  this 
way  loops  are  formed  which  are  at  first  solid.  These  solid  processes  are 
gradually  iiollowed  out  and  l)ccome  continuous  with  the  lumen  of  the 
vessel.  In  some  cases  the  lumen  of  the  vessel  gradually  follows  the 
formation  of  the  sprout.  In  other  cases  loops  are  formed  before  the 
communication  with  the  lumen  of  the  vessel  takes  place.  In  this  new 
formation  of  blood-vessels  there  must  be  a  process  somewhat  similar  to 
chemotaxis.  In  the  cornea  the  blood-vessels  are  always  formed  from 
that  portion  of  the  sclera  which  is  nearest  the  ulcer,  and  they  show  no 
tendency  at  all  to  extend  anywhere  but  into  the  cornea.  In  the  fonna- 
tion  of  the  loops  there  must  be  also  a  mutual  attraction  for  the  cells, 
because  the  meeting  of  the  pointed  process  from  the  same  or  from 
neighboring  vessels,  and  the  resulting  formation  of  loops,  cannot  be 
regarded  as  a  matter  of  chance.  This  new  formation  of  vessels  always 
proceeds  from  the  capillaries,  and  the  newly-formed  vessels  are  always 
of  this  character.  They  function  as  the  old  vessels.  When  the  inflam- 
mation continues  emigration  takes  place  from  them  as  readily  as,  or 
more  readily  than,  from  the  old  vessels.  They  are  more  easily  dilated, 
and  when  dilated  the  dilatation  frequently  persists  for  some  time.  Later, 
these  vessels  may  become  differentiated  into  Iroth  arteries  and  veins,  but 
the  manner  in  which  this  differentiation  is  ])roduced  has  not  been  fully 
made  out.  Other  modes  of  new  formation  of  the  vessels  have  Ijcen 
described.  According  to  some  authors,  the  cells  in  the  inflamed  part, 
the  cells  of  the  tissue,  may  collect  together  in  rows  and  may  become 


REPAIR  AND  REGENERATION. 


195 


changed  into  enclothelial  cells,  and  a  communication  be  established  be- 
tween the  old  vessel  and  the  newly-formed ;  or  large  cells  of  the  tissue 
may  become   holIo\\cd    out    and   "in    this    way  new    cells   are    formed. 


Fig.  9. 


:9, 


^& 


^>,^;^,g  ^'Ojo.:  i:.-v.-.,--u. 


';^/^r£.r^..:-'D. 


Hi^iiiiSi 


a 


Section  through  a  portion  of  a  suture  which  had  remained  in  the  tissue  eleven  months.  The 
suture  first  becomes  infiltrated  with  leucocytes,  and  the  formation  of  connective  tissue  takes 
place  as  in  Fig.  8.  The  section  represents  only  a  fragment  of  the  suture :  a,  a,  silk  flbrillse 
surrounded  by  dense  connective  tissue;  6,  6,  giant-cells  enclosing  iibrillae. 

Strieker  believes  tliat  not  only  are  new  vessels  formed  from  the  cells  in 
this  way,  but  that  there  may  be  a  new  formation  of  red  corpuscles  in 
the.se  vascular  cells  in  the  same  way  as  in  the  embryo.  The  essential 
cause  of  the  new  formation  of  blood-vessels  and  the  influence  which 
leads  to  it  are  obscure.  We  know  only,  in  general,  that  they  are  formed 
in  accordance  with  the  law  of  nutrition — that  where  more  blood  is 
required  for  a  part  it  will  be  given,  either  by  a  dilatation  of  the  old 
vessels  or,   if  this  be  hot  sufficient,  by  a  new  formation  of  vessels. 

There  has  been  considerable  controversy  with  regard  to  the  participa- 
tion of  the  leucocytes  in  the  new  formation  of  tissue.  Cohnheim  be- 
lieved that  not  only  were  all  the  cells  found  in  an  inflamed  part  leuco- 
cytes, but  that  any  new  formation  of  tissue  takes  place  from  leucocytes. 
He  was  led  to  this  belief  by  a  number  of  experiments.  He  showed 
that  there  could  be  a  new  formation  of  tissue  in  parts  in  which  all  the 
living  cells  were  destroyed  by  boiling  and  which  were  afterward  placed 
in  the  peritoneal   cavity  of  animals.     The   tissues  became   filled   with 


196  SURGICAL  PATHOLOGY. 

leucocytes  which  ■wuiidcn'd  into  tiicm,  and,  as  a  iiewly-foriuecl  connec- 
tive tissue  witli  blotxl-vessels  was  afterward  found  in  the  tissue,  he 
believed  that  this  new  formation  must  take  place  from  leucocytes.  Some 
experiments  which  Ziegler  made  on  this  siihject  seemed  to  \w  at  first  con- 
clusive. He  enclosed  two  thin  jtlatcs  of  li'lass  with  a  ca])illary  space  be- 
tween them  in  the  siibcntancous  tissue  or  in  the  peritoneum  of  an  animal, 
and  found  that  a  thin  laniclla  of  connective  tissue  was  formed  l)etw('cn 
the  plates  (Fig.  9).  The  first  thing  seen  in  such  conditions  is  a  filling 
up  of  the  spaces  between  the  plates  with  leucocytes  and  fibrin.  After- 
ward large  cells  with  a  round  nucleus  and  a  large  amount  of  protoplasm 
appeared,  and  from  these  large  cells  the  formation  of  connective  tissue 
takes  place,  either  by  a  diflt'erentiation  of  the  body  of  the  cell  into  fibrous 
tissue  or  by  a  sort  of  secretion  from  the  cell.  The  exact  method  in 
which  this  formation  takes  place  has  not  been  fully  made  out.  Ziegler 
supposed  that  these  large  cells  were  produced  directly  from  the  leuco- 
cytes, but  a  repetition  of  his  work  by  other  observers  has  shown  that 
they,  like  the  leucocytes,  wandered  into  the  glass  cell  from  without.  In 
any  ease  the  new  foriuation  of  tissue  seems  to  take  place  from  the 
large  protoplasmic  epithelioid  cells  (Fig.  8).  The  leucocytes  probably 
take  a  part  in  the  process,  but  only  a  passive  one.  Many  of  these 
large  cells  are  phagocytic  in  character,  and  it  is  probable  that  the  leuco- 
cytes play  a  distinct  part  in  furnishing  them  nutrition,  being  taken  up 
and  devoured  by  these  large  connective-tissue  cells. 

Sometimes  there  is  in  this  way  new  formation  of  cells  from  the  old, 
which  simply  supplies  the  tissue  which  has  been  lost.  In  this  new  for- 
mation of  cells  all  of  the  tissues  can  take  part.  It  is  proliable  that  the 
cells  most  actively  concerned  in  it  are  the  cells  of  the  small  blood-ves- 
sels. In  other  cases  there  is  not  an  immediate  formation  of  cells  from  the 
cells  of  the  old  tissue,  but  tliere  are  intermediate  steps.  The  new  tissue 
is  not  formed  directly  from  the  old,  Init  tliere  is  a  formation  of  granula- 
tion tissue  first.  In  the  cornea,  for  instance,  if  the  loss  of  substance  is 
extremely  small,  it  may  be  supplied  by  a  simple  new  formation  of  cells ; 
if  larger,  there  will  be  a  ])receding  formation  of  granulation  tissue. 
Some  of  the  granulation  cells  will  afterward  ditferentiate  themselves 
into  tissue-forming  cells.  The  tissue  which  is  formed  in  this  way  from 
the  granulation  tissue  is  never  so  perfect  as  that  formed  directly.  It 
always  approaches  the  character  of  cicatricial  tissue.  The  ])rocess  of 
regeneration  of  tissue  can  also  be  studied  on  the  ulcer,  and  in  the 
ulcer  we  can  also  study  the  local  conditions  which  may  interfere 
with  this  regeneration.  In  the  ulcer  the  regeneration  of  tissue  nuist 
take  place  in  two  directions.  There  is  not  only  a  new  formation 
of  necessary  tissue  from  the  connective  tissue,  but  a  new  f\)rniatioii 
of  epithelium  must  also  take  place.  Until  the  surface  is  covered 
over  Avith  epithelium  it  nuist  be  constantly  subjected  to  various  trau- 
matic influences  wliich  will  keep  up  the  inflammation.  If  the  ulcer 
is  small  and  the  local  conditions  favorable,  the  epithelium  will  grow  in 
from  the  edges,  cover  over  the  surface,  and  the  inflammation  will  sul)side. 
This  new  formation  of  epithelium  takes  place  solely  from  the  surround- 
ing epithelium.  It  has  been  supposed  by  many  that  a  new  formation 
of  epithelium  may  take  place  from  the  granulating  surface  of  the  ulcer. 
The  proof  of  this  was  supposed  to  be  shown  in  the  fact  that  the  growth 


IXFLAMMATION.  197 

of  cpitlielium  does  not  always  prow't'd  oveiily  from  the  edges,  but  small 
islands  of  epitlielliim  are  sometimes  formed  in  the  middle  of  the  uleer, 
and  from  these  a  growth  extends  upward  to  the  edges.  These  small 
islands  which  are  formed  in  the  centre  of  an  ulcer  do  not  represent  a 
new  formation  of  epithelium  from  the  edges  of  the  ulcer,  but  are  the 
remains  of  epithelial  tissues,  such  as  sweat-glands  or  the  sebaceous 
glands  of  the  skin,  wliich  were  not  entirely  destroyed  by  the  injury 
whicii  produced  the  ulcer.  An  ulcer  never  heals  by  a  simple  process 
of  tissue-formation,  such  as  is  seen  in  the  cornea,  but  there  is  always  a 
formation  of  granulation  tissue,  and  from  this  the  regeneration  proceeds, 
leading  to  the  production  of  cicatricial  tissue.  The  amount  of  cicatri- 
cial tissue  varies  with  the  extent  and  duration  of  the  ulcer.  It  is 
exceedingly  dense,  firm,  and  contains  few  bhiod-vessels.  It  may  extend 
into  the  surrounding  tissues  for  a  considerable  distance  beyond  the  actual 
seat  of  the  ulcer.  In  the  most  common  seat  of  ulceration,  the  anterior 
surface  of  the  lower  leg  and  ankle,  there  are  numerous  local  conditions 
wiiich  interfere  with  the  process  of  healing.  In  the  first  place,  the 
ulceration  is  constantly  repeated  at  the  same  spot.  The  tissue  is  not 
normal,  it  has  not  the  normal  vascular  supply,  and  it  reacts  to  injuries 
more  easily.  Not  only  is  there  this  abnormal  tissue  with  weak  vascular- 
ization, but  the  ulcers  usually  arise  in  persons  who  have  a  local  passive 
congestion.  In  the  process  of  healing  the  new  formation  of  blood-ves- 
.sels  does  not  so  readily  take  place.  As  we  have  seen,  in  spite  of  the 
apparent  vascularization  of  the  tissue  of  the  nicer,  it  is  really  poorer  in 
blood-vessels.  Frequently,  healing  will  not  take  place  until  the  dense 
cicatricial  tissue  resulting  from  a  series  of  old  ulcers  is  removed  in  toto, 
or  until  incisions  be  made  through  it  so  as  to  allow  vascularization  to 
take  place  from  the  deeper  and  more  healthy  tissues  beneath  it. 

The  Effect  of  Inflammation  on  the  Body  as  a  Whole. 

The  objection  was  early  made  to  the  theor}'  of  inflammation  of  Cohnheim 
that  all  of  the  cells  found  in  the  inflamed  part  could  not  come  from  the 
blood,  because  there  were  not  enough  cells  in  the  blood  to  produce  these. 
In  an  acute  fibrinous  pneumonia  one  entire  lung  and  a  portion  of  the  other 
may  lie  so  filled  uj)  with  tJie  inflanunatory  exudation  as  to  resemble  a 
.solid  mass  and  to  sink  in  water.  The  consolidation  of  the  lung  is  due 
in  large  part  to  an  accumulation  of  leucocytes,  and  in  a  case  of  advanced 
pneumonia  the  number  of  leucocytes  in  the  lung  could  not  be  estimated 
by  numbers,  but  by  pounds.  The  same  thing  is  true  in  the  large  puru- 
lent exudation  which  we  find  in  empyema  or  in  peritonitis.  There 
are  at  no  time  enough  leucocytes  in  the  blood  to  form  such  masses 
even  if  all  of  them  could  be  tpken  u]).  It  was  supposed  also  that 
after  the  leucocytes  had  emigrated  from  the  vessels  they  multiplied, 
and  that  many  of  them  could  he  newly  formed  from  those  whicli  at 
first  emigrated.  In  speaking  of  this  Cohnheim  says  that  in  general 
we  can  form  little  idea  of  the  number  of  leucocytes  in  the  blood  from 
microscopic  observation,  because  large  luunbers  of  leucocytes  break  up 
and  disajipear  the  moment  the  blood  is  taken  on  the  slide  for  examina- 
tion. He  also  suggests  that  there  may  be  a  new  formation  of  leuco- 
cytes in  the  blood,  and  an  increase  in  their  number  due  to  this.     He 


198  SURGICAL  PATHOLOGY. 

called  attention  to  the  enlargement  of  the  lymphatic  glands  and  spleen 
frecjuently  seen  in  acute  inflammation,  and  supposes  that  this  may  in 
some  way  stand  in  relation  to  the  number  of  leucocytes  found  in 
the  exudation.  Cohnheini,  however,  made  no  estimate  of  the  supposed 
increased  number  of  leucocytes  in  the  blood.  As  early  as  1842,  Gul- 
liver called  attention  to  the  similarity  between  the  pus-eells  and  the 
leucocytes,  and  thought  that  in  inflammation  the  white  corpuscles  of  the 
blood  were  increased  ;  and  he  instances  a  case  in  which,  in  a  stallion 
which  had  a  large  abscess,  the  white  corpuscles  of  the  blood  were  almost 
as  numerous  as  the  red.  Virchow  also,  in  his  study  of  the  blood  in  Icu- 
cicmia,  recognized  the  fixct  that  in  most  acute  inflannnatioiis,  especially 
if  they  were  at  all  extensiv'e,  the  white  corpuscles  of  the  blood  increased 
in  number.  He  supposes  that  this  is  due  to  the  fact  that  the  lymph- 
glands  and  other  blood-forming  organs  undergo  a  stimulation  which 
excites  them  to  an  increased  activity.  We  know  now  that  in  any  inflam- 
mation, and  especially  in  an  infectious  inflammation  characterized  by 
extensive  exudation  and  emigration,  the  white  corjiuscles  arc  increased. 
It  is  only  recently,  when  the  study  of  the  corpuscular  elements  of  the 
blood  has  received  great  attention,  that  the  extent  and  importance  of  this 
leueocytosis  have  been  recognized.  The  leucocytosis  keeps  almost  an  exact 
pace  with  the  fever  and  the  extent  of  the  exudation.  In  croupous  jineu- 
monia  we  liave  the  greatest  extent  of  leucocytosis,  and  the  number  of 
leucocytes  in  the  blood  may  be  double  or  treble  that  of  normal.  The 
leucocytes  which  are  found  in  increased  number  are  exclusively  of  the 
polynuclear  variety.  The  feet  that  in  inflammations  uncomplicated  with 
hyperplasia  of  the  lymphatic  glands  there  is  no  increase  in  the  mono- 
nuclear leucocytes  speaks  against  the  emigration  of  these  and  their  taking 
part  in  the  exudation.  The  uKinonuclear  leucocytes  are  increased  in 
tyjihoid  fever  and  in  other  processes  connected  with  a  lymphatic  hyper- 
])lasia.  The  recognition  of  a  ]>olynui-lear  leucocytosis  in  the  blood  is 
frequently  of  great  importance  in  determining  the  character  and  extent 
of  inflammation.  Wc  find  other  changes  in  the  blood  in  addition  to  the 
leucocytosis,  but  they  jirobably  depend  in  large  measure  ujion  this.  If 
the  inflammation  is  suiticiently  extensive  and  lasts  long  enough  to  inter- 
fere M'ith  the  general  nutrition  of  the  liody,  a  diminution  in  the  number 
of  red  corpuscles  may  take  ])lace.  In  acute  inflammations,  especially 
when  connected  with  an  extensive  leucocytosis,  there  is  an  increase  in 
the  fibrin  of  the  blood.  This  has  long  been  known,  and  M'as  formerly 
used  as  a  diagnostic  means  for  recognizing  the  extent  and  character  of 
an  inflammation.  Although  the  fibrin  is  increased  in  the  Idood  in 
inflammation,  it  coagulates  more  slowly.  Tliis  slow  coagulation  of  the 
blood  allows  the  red  corpuscles  to  sink  from  the  surface  of  the  blood 
before  coagulation  takes  place.  As  a  result  of  this,  on  the  surface  of 
the  clot  there  is  a  layer  of  coagulation  which  has  a  buify  or  straw  color. 
This  is  known  as  the  buify  coat  of  the  blood,  and  in  the  old  days  of 
bloodletting  a  great  deal  of  imjiortance  was  attached  to  it.  Fever  is  a 
frequent  accompaniment  of  inflammation. 


FEVER.  199 


II.  FEVER. 


Fever  can  well  be  considered  in  connection  witii  inflammation,  for 
it  is  an  almost  constant  accom])animeut  of  it,  and  the  etfect  on  the  general 
organism  of  a  local  inflammation  is  shown  first  of  all  in  the  production 
of  fever.  In  fever  the  normal  temperature  of  the  body  is  increased. 
Usually  this  increased  temperature  is  accompanied  by  other  abnormal 
conditions,  but  these  are  not  necessary  to  the  condition.  Observations 
on  normal  individuals  sIkjw  that  the  temperature  of  the  body,  in  spite 
of  variation  in  the  surroiniding  temperature  and  in  spite  of  all  sorts  of 
changes  in  the  external  conditions  of  life,  has  a  medium  value  of  37.2° 
to  37.4°  C.  The  absolute  variations  in  the  course  of  the  day  may  be 
from  1°  to  2.5°  C.  The  body  is  able  to  maintain  such  a  temperature,  far 
above  tliat  of  the  surrounding  medium,  only  by  the  production  of  heat 
by  means  of  chemical  processes  taking  ]ih\ce  in  the  tissues.  The  produc- 
tion of  heat  is  oftset  by  a  discharge  of  heat,  which  takes  place  by  means 
of  the  skin,  the  lungs,  and  the  various  excreta  of  the  body.  Ordinarily, 
the  production  of  heat  and  the  discharge  of  heat  are  so  evenly  balanced 
that  the  temperature  of  the  body  remains  the  same  in  all  conditions. 

The  Production  of  Heat. 

The  various  chemical  processes  which  take  place  in  the  body  are 
accompanied  by  the  production  of  heat.  At  every  muscular  contraction, 
in  all  the  processes  of  glandular  secretion,  heat  is  produced.  Of  all  the 
tissues  of  the  body,  the  muscles,  not  only  from  their  bulk,  forming  as 
they  do  a  large  part  of  the  whole  frame,  but  also  from  the  character  of 
their  metabolism,  must  be  regarded  as  the  ciiief  source  of  heat.  Not  only 
is  heat  produced  in  the  contractions  of  the  muscles,  but  during  their 
quiescent  period  metabolic  changes  are  taking  place  in  them  by  which 
heat  is  produced.  Next  in  importance  to  the  muscles  are  the  various 
secreting  glands.  Tlie  secreting  elements  of  the  glands  in  the  periods  of 
secretion,  and  pi'obably  in  the  cpiiescent  period,  are  in  a  state  of  meta- 
bolic activity  which  must  give  rise  to  heat.  In  the  case  of  the  salivary 
gland  the  temperature  of  the  saliva  secreted  during  stimulation  of  the 
chorda  tympani  is  1°  to  1.5°  higher  than  that  of  the  blood  in  the  carotid 
artery.  The  blood  in  the  hepatic  vein  is  the  warmest  in  the  body.  In 
the  dog  a  temperature  of  40.73°  has  been  observed  in  the  hepatic  vein, 
while  tiiat  of  the  vena  cava  was  38.35°  and  tliat  of  the  right  lieart  37.7°. 
The  brain,  too,  may  be  regarded  as  a  source  of  heat,  since  its  temjierature 
is  higher  than  that  of  the  arterial  blood  with  which  it  is  supplied.  The 
other  tissues  of  the  body  also  serve  as  sources  of  heat,  but  the  part  they 
play  is  insignificant  as  compared  with  the  muscles  and  glands. 

The  increase  of  temperatui-e  of  the  bfxly  in  fever  may  I)e  due  to 
either  of  two  conditions  :  There  may  be  increased  production  of  heat, 
the  discharge  being  the  same  or  even  increased,  or,  the  production  being 
the  same,  the  discharge  of  heat  may  be  reduced.  One  of  the  best 
known  of  the  theories  of  fever  was  that  advocated  by  Traube.  Accord- 
ing to  his  views,  there  was  no  increased  production  of  heat,  but  the 
increased  temperature  was  due  to  a  decrease  in  the  discharge  of  heat. 
The  discharge  of  heat  lie  supposed  to  be  least  in  the  earlier  period  of 


200  SURGICAL   PATHOLOGY. 

fevor  and  increased  in  tiic  (icf'crv<'8eence.  A  great  deal  of  work  lias  been 
done  to  determine  wlietlier  there  is  increase  of  heat  in  fever,  and  its 
degree.  Various  methoils  have  been  used  to  determine  this.  The  heat 
being  the  residt  of  eheniieal  elianges  in  the  body,  it  was  sought  to  deter- 
mine if  these  chemical  ciianges  were  more  active  in  fever.  It  is  known 
tiiat  most  fever  patients  lose  weight  and  that  there  is  increased  consumji- 
tion  of  tissue.  Tiic  urea  is  increased,  and  for  a  long  time  it  was  believed 
that  the  increased  excretion  of  urea  att'ordcd  satisfactory  evidence  of 
increased  oxidation  and  incrmscd  production  of  heat.  Of  late  years 
investigations  have  been  made  upon  the  consumption  of  oxygen  and  the 
])roduction  of  carbonic  acid  in  fever,  and  it  is  found  that  there  is  an 
increase  in  the  amount  of  oxygen  consumed  and  in  the  carbonic  acid 
given  off.  In  the  Ix'ginning  of  fever,  when  the  temperature  is  con- 
.stantly  rising,  both  of  these  processes  are  most  active  ;  during  the  stage 
of  defervescence  the  consumption  of  oxygen  may  fall  below  the  normal. 
It  has  been  claimed  that  the  increased  oxidation  was  not  the  cause  of  the 
fever,  but  simply  resulted  from  the  increased  temperature  of  the  body. 
Although  it  is  true  that  there  is  an  increase  of  oxidation  in  increased 
temperature,  the  elevation  of  the  temperature  1°  C.  would  only  increase 
the  oxidation  3.3  per  cent.,  while  in  fever  the  oxidation  may  be  increased 
l."J-15  per  cent.  Although  it  has  been  generally  accepted  that  in  fever 
there  is  increased  oxidation  of  tissues  and  increased  production  of  heat, 
this  alone  would  not  be  sufficient  to  explain  the  high  tem])crature.  The 
increase  in  heat-production  in  fever  is  far  less  than  would  take  ])lace  in 
an  individual  making  active  muscular  movements  in  a  cold  environment. 
In  health  the  increased  heat-production  is  met  by  a  correspontling  dis- 
charge of  heat,  so  that  it  has  no  effect  on  the  body  temperature.  The 
loss  of  heat  in  fever  has  been  investigated  by  direct  calorimetry.  The 
discharge  of  heat  is  least  during  the  initial  stage  of  fever,  and  increases 
during  the  stage  of  defervescence.  During  the  hot  stage  the  discharge 
of  heat  exceeds  the  normal,  but  usually,  on  account  of  the  dryness  of 
the  skin,  is  not  so  great  as  might  be  inferred  from  placing  the  hand  on 
the  surface.  In  the  febrile  chill  not  only  is  the  discharge  of  heat  by  the 
contraction  of  the  vessels  of  the  skin  reduced  to  a  minimum,  but  heat- 
production  is  excited  to  the  utmost.  As  the  result  of  the  work  of  most 
investigators  it  may  be  said  that  in  fever  both  heat-jjroduction  and  heat- 
discharge  are  increased. 

Recently,  Rosenthal,  %\hi)  has  investigated  this  question  by  means  of 
a  specially  constructed  air-calorimeter,  using  animals  in  whom  fever  was 
produced  by  the  injection  of  various  substances  into  the  circulation,  has 
returned  to  the  view  of  Traube.  He  finds  that  in  the  initial  stage  of 
fever  and  in  the  stage  of  gradual  increase  of  temperature  the  discharge 
of  heat  is  diminished  and  there  is  no  increased  production  of  heat. 
When  the  fever  has  lasted  a  considerable  time  there  is  a  return  to  the 
normal  discharge  of  heat.  The  diminution  in  the  discharge  of  heat  he 
thiidis  is  due  to  sudden  changes  in  the  circulation  of  the  skin  brought 
about  by  vasomotor  influences.  In  the  stage  of  defervescence  the  dis- 
charge of  heat  is  greatly  increased,  and  al)out  corresponds  to  the  decrease 
in  the  temperature. 

If  the  regulatory  mechanism  were  normal,  the  discharge  of  heat  in 
fever  would  be  increased  in  proportion  to  the  increased  production  and  the 


FEVER.  201 

temperature  would  he  unaltered.  The  regulating  mechanism,  although 
jjrofoiindly  disturhcd,  is  not  jjaralyzed  in  fever.  External  cold  in  f'e\er 
to  some  extent  stimulates  the  heat-produetiun,  but  not  nearly  to  the  same 
extent  as  in  health.  A  person  in  te\-er  is  not  able  to  maintain  his  tem- 
perature under  the  influence  of  heat  and  cold  to  the  same  extent  as  a 
person  in  health.  It  is  not  merely,  as  some  have  sujiposed,  that  the 
regulatory  mechanism  is  set  for  a  higher  degree  (jf  heat,  but  that  it  is 
disturbed.  In  both  health  and  fever  tlie  regulatory  mechanism  is  under 
the  control  of  nervous  inHueni'c.  This  acts  through  the  vasomotor 
nerves  jiresiding  over  the  sujjerticial  parts  of  the  body,  and  Ijy  producing 
variations  in  the  calibre  of  the  cutaneous  vessels  controls  in  great  meas- 
ure the  discharge  of  heat.  The  jiersjjiration  which  plays  so  great  a  part 
in  the  discharge  of  heat  by  evaporation  is  also  under  the  influence  of  the 
nervous  system.  Heat-regulation  is  effected  not  only  by  means  of  varia- 
tions in  heat-discharge,  but  heat-production  is  also  under  the  influence 
of  the  nervous  system.  In  a  cold  atmosi)here  more  heat  is  produced, 
and  in  a  warm  less  heat,  provided  the  external  temperature  is  not  so 
high  or  so  low  as  to  make  it  impossible  to  preserve  the  body  tempera- 
ture. To  regulate  the  temperature  simply  by  the  discharge  of  heat 
would  be  like  regulating  the  temperature  of  a  room  by  opening  the 
doors  and  windows  and  paying  no  attention  to  the  furnace.  There  is 
every  reason  to  believe  that  nervous  impulses  control  chemical  changes 
which  result  in  the  production  of  heat  independently  of  visible  altera- 
tions of  the  tissues,  so  that  heat-production  is  in  considerable  part  under 
the  control  of  the  nervous  system.  The  nerves  controlling  the  produc- 
tion of  heat  are  known  as  thermic  nerves,  and  they  ai'c  controlled  by  cen- 
tres in  the  brain.  The  chief  of  these  centres  is  in  the  nucleus  caudatus, 
and  if  this  centre  is  stimulated  by  puncture  with  a  needle  or  by  electri- 
cal stimulation,  fever,  often  reaching  several  degrees  above  the  normal, 
will  result.  A  number  of  cases  have  been  collected  in  which  fever  re- 
sulted in  man  from  injuries  involving  these  centres  in  the  brain.  It  is 
very  probaljle  that  fever  may  lie  the  result  of  the  stimulation  of  these 
centres  in  the  brain  by  pyrogenic  substances  in  the  blood.  Opposed  to 
this  is  the  hiemic  thecny,  which  assumes  that  the  increased  temperature 
is  due  to  the  direct  action  on  the  tissues  of  pyrogenic  substances  con- 
tained in  the  blood.  After  puncture  or  stimulation  of  the  caudate 
nucleus  of  animals  they  present  all  the  phenomena  of  fever.  There  is 
increased  heat-production,  with  increased  consumption  of  oxygen,  and 
the  heat-regulaticin  is  also  interfered   with. 

Liebermeister  regarded  all  tlie  phenomena  of  fever,  the  changes  in  the 
pulse,  respiration,  etc.,  as  due  simply  to  the  eftect  of  the  increased  tem- 
perature. He  urged  that  the  weakness  of  the  heart,  which  is  undoubt- 
edly one  of  the  most  -serious  dangers  in  fever,  was  due  to  the  increased 
tem])erature,  which  caused  parenchymatous  and  fatty  degeneration  of  the 
cardiac  muscle.  According  to  his  views,  the  one  great  indication  in 
treatment  was  to  lower  the  temperature  of  the  body.  Of  late  there 
has  l)een  a  reaction  against  these  \iews  of  Liebermeister,  which  reaction 
has  in  part  been  brought  about  by  the  fact  that  antipyretic  drugs  may 
reduce  the  temperature,  but  may  not  affect  the  other  phenomena  of" 
fever.  Some  authors  have  gone  to  the  extent  of  not  only  denying  that 
there  is  danger  in  temperatures  whidi  do  not  exceed  a  very  high  point, 


202  SURGICAL  PATHOLOGY. 

hut  of"  stating  that  the  elevation  of  temperature  in  itself  may  be  a  benef- 
ieent  provision  of  nature  in  warding  off  the  effects  of  disease.  It  is 
obvious  that  the  effects  of  high  temperature  cannot  be  studied  in  the 
fevers  of  man  nor  in  the  artificial  fevers  produced  by  the  injection  of 
various  substances  into  the  blood.  The  effects  of  the  temperature  must 
be  separated  from  the  effects  produced  on  the  tissues  by  the  agents  wiiich 
cause  the  increase  in  temperature.  The  eflects  of  temperature  alone 
have  been  studied  by  subjecting  animals  to  a  high  temj)erature.  Some 
of  the  earlier  experiments  have  seemed  to  bear  out  Liebermcister's  view 
of  fever.  It  was  found  that  animals  whose  temperatures  were  artificially 
raised  to  40.-5°  or  41.7°  C  showed  evidences  of  illness.  All  experi- 
menters agree  that  a  mammalian  animal  dies  when  its  temperature  is 
raised  to  44°  or  45°  C.  Death  is  preceded  by  convulsions,  and  rigor 
mortis  develops  almost  immediately  after  death.  Death  in  these  cases 
has  been  attributed  to  heart-paralysis  due  to  lieat-rigor,  but  it  is  known 
that  heat-rigor  does  not  take  place  at  such  tenijieratures.  In  all  of  the 
cases  in  Mhich  death  took  place  after  keeping  the  animal  for  some  time 
at  a  temperature  of  40.5°-41°  fatty  degeneration  of  the  heart  was  found. 
The  most  complete  set  of  experiments  on  the  influence  of  high  tem- 
perature alone  was  made  by  Welch  at  the  Johns  Hopkins  Hospital.  In 
all  the  jirevious  experiments  the  animals  were  kejit  in  small,  dark,  badly- 
ventilated  boxes,  and  the  influence  of  the  high  temperature  was  assisted 
by  the  bad  surroundings  of  the  animals.  In  Welch's  experiments  the 
animals  were  kept  in  a  large  box  partially  closetl  at  tiie  top  by  a  blanket. 
The  box  was  surrounded,  except  at  the  top,  by  a  layer  of  water.  The 
animals  were  supplied  with  an  abundance  of  green  food  and  water, 
which  they  took  greedily.  He  succeeded  in  keeping  two  large  black 
rabbits  for  two  weeks  with  an  average  rectal  temperature  in  one  of 
41.4°  C.  and  in  the  other  41.8°.  The  animals  lost  weight  while  in  the 
box  in  spite  of  their  abundant  food,  but  otiicrwise  seemed  perfectly 
well.  He  found  considerable  differences  in  different  individuals  in 
their  capacity  of  withstanding  high  temperatures,  and  thinks,  in  gen- 
eral, that  black  rabbits  are  more  resistant  than  white.  In  all  cases, 
after  keeping  the  animals  for  some  time,  extensive  fatty  degeneration 
of  the  heart,  liver,  and  kidneys  was  found.  He  is  not  inclined  to 
attach  so  much  clinical  imi)ortance  to  the  fatty  degeneration  of  the 
heart  as  some  have  done.  In  a  series  of  experiments  which  he  made  on 
animals  in  whom  fsitty  degeneration  of  the  heart  had  been  produced  by 
heat  he  found  that  the  blood-jjressure  was  kej)t  at  the  usual  height,  and 
the  heart  reacted  to  nervous  stimulation  in  the  usual  way.  In  one  case 
he  observed  tlie  contraction  under  the  microscope  of  some  fibres  of 
heart-muscle  in  which  the  fatty  degeneration  was  so  advanced  that  no 
striation  could  be  seen.  He  thinks  from  this  that  the  effect  of  fever  on 
blood-pressure  is  not  due  to  increased  temperature  alone,  but  to  other 
factors.  Animals  which  had  been  rendered  ana?mic  by  bleeding  were 
more  affected  by  increased  temperature  than  normal  animals.  Animals 
with  an  artificially  increased  temperature  had  their  cajiacity  for  temper- 
ature regulation  disturbed,  so  that  they  were  more  suscej)tilile  to  the 
effects  of  heat  and  cold  than  normal  animals.  The  various  fevers  differ 
materially  in  the  eflects  jiroduced.  In  rclajjsing  fever  temperatures  can 
be  withstood  which  in  typhoid  fever  or  pneumonia  would  be  fatal. 


FEVER.  203 

In  fever  the  frequency  of  respiration  is  increased.  This  has  been 
atti'ibuted  to  tlie  direct  etJ'ect  of  tlie  heated  l)lood  ii])on  tlie  respiratory 
centres  in  the  meduHa.  The  experiments  of  Goklstein  made  in  Fick's 
laboratiny  are  <ienerally  quoted  as  completely  settling  this  point.  He 
surrounded  the  carotid  arteries  with  tubes  in  which  hot  water  circulated, 
and  found  the  respirations  increased.  In  order  to  produce  any  appre- 
ciable increase  of  temperature  in  the  blood  rapidly  flowing  tlirougli  the 
artery,  l)y  exposing  the  vessels  for  a  space  of  a  few  cm.  to  warmer  sur- 
rounilings,  tlie  tube  around  the  vessel  would  have  to  be  very  h()t,  and 
a  high  temperature  in  the  surrounding  tube  woukl  have  so  injured  the 
vessel  that  coagulation  would  take  place.  Sihler  repeated  tke  experi- 
ments of  Goldstein,  and  concluded  tliat  the  increase  in  the  respiration 
was  not  due  to  heating  tlie  blood,  but  to  stinudation  of  tke  peripkeral 
nerves.  AVelck  found  that  in  tlie  hot  box  animals  with  a  surrounding 
temperature  of  32°-35°  C.  often  preserve  tlieir  normal  temperature, 
though  the  respirations  .are  increased.  When  animals  with  fever  are 
taken  out  of  the  box  the  respiration  often  decreases  before  the  temper- 
ature falls.  The  increased  frequency  of  the  heart's  action  is  due  to  the 
direct  action  of  the  heated  blood  on  tke  cardiac  muscle.  Tkis  lias  been 
shown  by  Martin  on  the  isolated  mammalian  lieart.  Wken  the  heart 
is  fed  with  blood  of  gradually  increased  temperature,  the  rapidity  of 
the  heart  uj)  to  a  certain  degree  keeps  pace  witk  the  increased  temj)er- 
ature.  The  heart  continues  to  beat  when  supplied  with  blood  of  a 
much  higher  temperature  than  is  found  in  fever.  The  nervous  phe- 
nomena of  fever  cannot  be  attributed  to  the  effect  of  high  temperature 
on  the  nervous  centres,  for  the  effect  of  fever  on  the  nervous  centres 
may  be  entirely  absent  in  relapsing  fever  and  in  the  asejjtic  wound- 
fever. 

Fever  may  be  due  to  an  infinite  number  of  causes.  In  general  the 
fevers  are  divided  into  the  symptomatic  and  the  essential,  though  no  sharp 
line  can  be  drawn  between  the  two.  In  the  symptomatic  fevers  it  is 
assumed  that  there  are  local  lesions  soinewkere  in  tiie  body  from  which 
substances  are  produced  which  when  absorbed  cause  fever.  At  one  time 
there  was  a  theory  that  in  an  intlanunatory  focus  there  was  a  direct  pro- 
duction of  heat,  and  fever  was  the  result  of  this  local  heat-formation. 
In  a  strict  sense  there  are  no  essential  fevers,  and  the  distinction  is  a 
purely  artificial  one.  Fever  is  generally  due  to  the  jiresence  in  the 
blood  of  substances  which  are  ca}>able  of  causing  it,  and  to  which  the 
name  pyrogcuic  has  been  given.  A  great  deal  of  work  has  lieen  done 
of  late  in  the  investigation  of  these  substances.  Most  of  the  normal  fer- 
ments of  the  body,  particularly  fibrin-ferment,  may  give  rise  to  fever 
when  injected  into  the  blood.  Of  great  interest  in  this  connection  is  the 
aseptic  fever  which  was  described  by  Volkmann.  It  follows  injuries  to 
the  tissue  in  which  there  is  no  ])ossible  infection.  Nothing  shows  more 
clearly  the  line  which  should  l>e  drawn  between  the  high  temperature 
and  the  other  phenomena  of  fever.  Tiiis  aseptic  fever  has  no  prognostic 
importance.  In  a  case  of  subcutaneous  fracture,  with  extravasation  of 
blood  into  the  tissues,  temperatures  of  40°  C.  or  over  may  be  seen  without 
any  other  phenomena  of  fever  save  slightly  increased  pulse  and  resjii- 
ration. 

Absorption  of  perfectly  ase|)tic  products  of  tissue-necrosis  will  give 


204  SURGICAL  PATHOLOGY. 

rise  to  fever.  Gaiifrolplie  and  C'onmiont  have  sliown  that  the  injection 
of  the  fjerm-free  tissue-jiiiee  from  j^anijrenous  tissues  is  in  a  hiu;h  dcg'ree 
pyrojrenic.  They  also  prixhiced  net^-osis  in  the  testicle  by  means  of  a 
IJiiatMre,  and  fonnd  tliat  the  fluid  of  tlie  necrotic  tissue  produced  fever. 
Tile  jMiwer  of  filiiiu-fcrnient  in  producing  fever  is  well  known.  Any 
sulistance  which  will  give  rise  to  it  acts  as  a  pyrogenic  agent.  Thus 
water  injected  into  the  blood  will  give  rise  to  fever.  It  lias  been  clainicd 
that  most  of  the  substances  which  produce  fever  act  by  producing  coag- 
ulation in  the  capillaries  and  small  blood-vessels,  and  so  giving  rise  to 
tibrin-ferment.  Hildenbrandt  found  that  after  the  injection  of  various 
ferments  into  the  blood  there  was  extensive  thrombosis  of  the  small 
vessels  in  the  liver,  intestine,  lungs,  and  kidney.  The  presence  of  fibrin- 
ferment  cannot  be  regarded  as  the  sole  cause  of  the  fever,  for  the  highest 
temperatures  are  not  found  in  the  diseases  in  which  the  greatest  quantity 
of  ferment  is  found  in  the  blood,  and  fever  may  be  present  in  cases  in 
which  this  ferment  is  entirely  absent. 

It  is  questionable  whether  fever  may  be  the  result  of  irritation  of 
the  peripheral  nerves.  The  cases  usually  cited  as  e.\am|)les  of  this  are 
the  fever  of  children  during  teething  and  the  fever  which  sometimes 
follows  the  introduction  of  a  catheter.  It  does  not  seem  reasonable  that 
all  eases  of  catheterization  fever  should  be  ascribed  to  the  introduction 
of  bacteria  or  to  injury  of  the  urethra.  There  are  numbers  of  eases  in 
which  the  careful  introduction  of  an  aseptic  catheter  has  been  followed 
by  a  chill  and  fever  lasting  a  short  time.  The  chill  may  follow  so  shortly 
after  the  introduction  of  the  catheter  that  time  is  not  given  for  the  in- 
crease of  Ijacteria  should  any  have  been  brought  with  it,  and  it  is  not 
probable  that  the  pyrogenic  substances  produced  by  bacteria  elsew^here 
are  on  the  catheter.  Nor  is  time  given  for  the  development  of  sufficient 
iuHanunation  to  cause  fever  even  if  an  injury  was  produced  by  the  catheter. 
In  many  cases  a  temporary  increased  tenqierature  is  the  only  phenomenon. 
The  case  is  different  when  fever  follows  the  introduction  of  a  catheter 
into  an  inflamed  urethra  or  bladder.  In  regard  to  the  question  of  pro- 
duction of  fever  from  peripheral  irritation,  a  strong  argument  against  it 
is  that  it  is  only  in  certain  ])arts  of  the  body  that  such  irritation  is  followed 
by  fever.  No  irritation  of  the  skin  in  general  which  is  not  followed  by 
inflammation  will  produce  fever.  In  the  inflamed  bladder  or  urethra  the 
pvrogenic  material  is  already  jircsent,  and  sufficient  injury  may  lie  pro- 
duced to  cause  its  absorption.  Most  of  the  chemical  products  of  bacteria 
are  pyrogenic.  These  may  be  absorbed  into  the  circulation  from  a  local 
lesion  of  some  sort,  or  they  may  be  absorbed  from  the  alimentary  canal 
without  any  local  lesions  being  present.  There  is  no  doui)t  that  abnormal 
processes  of  fermentation  in  the  alimentary  canal  may  ])roduce  chemical 
substances  which  when  al)sorl)ed  may  give  rise  to  increased  temperature 
and  the  other  phenomena  of  fever. 

It  is  easy  to  see  why  inflammation  should  be  so  constantly  accom- 
panied by  fever.  In  the  inflammatory  exudation,  whether  of  an  aseptic 
<n-  septic  character,  substances  are  present  which,  when  absorbed,  are 
pyrogenic.  Not  only  is  there  in  every  case  fibrin-ferment,  but  the  prod- 
ucts of  simple  necrosis  of  tissue  are  pyrogenic.  If  the  inflammation  be 
due  to  Ijacteria,  there  are  added  to  the  pyrogenic  substances  of  the  exu- 
dation the  chemical  substances  produced  by  the  bacteria.     If  there  is  no 


THROMBOSIS  A^^D  EMBOLISM.  205 

accumulation  of  the  exudation  in  tlic  tissue^:  and  no  absorption,  fever 
does  not  take  place.  In  wounds  treated  by  the  open  method,  where  the 
products  of  the  inflammati(jn  are  not  absorbed,  there  is  no  fever  unless 
the  inflammation  extends  into  the  surrounding  tissues  and  allows 
absorption  from  these.  The  <lependence  of  fever  upon  abs()r])tion  is 
.shown  in  its  prompt  decline  when  an  intlannnatory  exudation,  especially 
if  it  be  purulent,  is  evacuated.  There  is  good  evidence  that  the  increased 
temperature  in  fever  i.<  not  in  itself  a  source  of  danger  unless  it  reaches 
a  very  high  degree.  There  is  also  some  evidence  that  the  increase  of 
temperature  may  not  be  an  evil,  but  a  beneficent  agent.  The  most 
dangerous  cases  of  pneumonia  are  frequently  not  those  in  which  the  tem- 
perature is  highest.  Serottin  has  found  that  wiien  sterilized  cultures  of 
typhoid  Ijaci'li  are  injected  into  the  blocid  of  rabbits,  recovery  is  more 
apt  to  take  place  when  the  temjierature  is  elevated,  ^^'elch  has  observed 
the  same  thing.  Cases  of  typhoid  fever  of  especial  malignity  have  been 
reported  in  which  the  temperature  was  subnormal  throughout.  It  is  no 
longer  the  custom  to  judge  the  severity  of  wouud-fever  In-  the  degree  of 
the  temperature  elevation.  Many  surgeons  consider  tiie  condition  of  the 
circulation  and  <ither  things  of  far  more  prognostic  value  than  the  evidences 
given  by  the  thermometer.  Dochman  found  that  when  cats  were  given 
curare  the  poisonous  influence  of  the  drug  was  far  less  when  the  animals 
were  given  a  temperature  of  40°  C.  by  keejiing  them  in  the  warm  chamber 
than  when  they  were  kept  in  ordinary  temj>eratures.  A\'hile  there  were 
apparently  no  symptoms  produced  in  the  heated  animals,  poisoning  rapidly 
developed  when  they  were  exposed  to  ordinary  temperatures.  He  further 
calls  attention  to  the  fact  that  all  infectious  diseases  accompanied  by  fever 
have  a  tendency  to  recover,  while  the  afebrile  infectious  diseases,  such  as 
leprosy  and  rabies,  have  no  tendency  to  recover. 

From  all  we  have  seen  of  inflammation  it  seems  evident  that  its 
])lienomena  are  essentially  conservative  in  their  action  on  the  organism, 
and  it  cannot  be  assumed  that  so  marked  a  phenomena  as  the  lever 
should  have  the  opposite  tendency.' 


m.  THROMBOSIS  AND  EMBOLISM. 

Thrombosis. 

Thrombosls  is  the  coagulation  of  the  blood  in  the  vessels  during  life. 
When  blood  is  taken  from  the  vessels  during  life,  after  standing  some 
time  it  undergoes  coagulation,  changing  from  a  fluid  to  a  solid  form, 
and  the  vessel  containing  it  can  be  inverted  without  spilling  tlu'  I'ontents. 

We  owe  the  most  of  our  knowledge  of  the  process  of  coagulation 
and  the  factors  concerned  in  it  to  the  work  of  Alex.  Schmidt  and  his 
pupils.  Schmidt  was  able  to  separate  from  the  blood  two  substances, 
each  with  definite  chemical  ])roperties,  to  one  of  which  he  gave  the 
name  of  paraglobulin  and  ti>  the  other  the  name  of  filn-inogcn.  The 
fibrin  of  the  blood  does  not  exist  pre-formed  in  the  blood,  but  is  due  to 

'  In  these  remarks  on  fever  extensive  use  has  been  made  of  the  Cartwright  Lectures 
on  fever  by  Prof.  W.  H.  Welch. 


20(5  SURGICAL  rATHOLOGY. 

the  union  of  thoso  two  sulistanccs,  tlie  union  licinfj;  iironfjlit  about  l)y  tiie 
presence  of  a  thinl  .suii.stanee  ^\•llieil  lias  all  the  characters  of  a  fei'nient, 
and  which  is  called  fibrin-ferment.  This  ferment  is  destroyed  or  ren- 
dered inoperative  at  the  death-jjoint  of  protoplasm  and  of  the  other  fer- 
ment-substances of  the  body  ;  that  is,  at  about  58°  C.  If  the  blood  be 
heated  to  58°  C.  before  any  coagulation  has  taken  place,  the  power  of 
undergoing'  coagulati()n  is  lost.  The  ferment  appears  to  be  principally 
contained  in  the  white  corpuscles  and  is  set  free  by  their  disintegration. 
Other  tissues  of  the  body  may  contain  this  substance,  or  substances 
M'hich  are  analogous  to  it  and  which  act  in  the  same  way.  A  proteid 
substance  may  be  obtained  from  the  thymus  gland  whic^li  when  injected 
into  the  circulation  pi-oduces  extensive  coagulation  in  all  the  vessels  and 
leads  to  the  death  of  the  animal.  The  disintegration  of  other  tissues  of 
the  body  also  produces  fibrin-ferment.  In  necrosis,  sul)stances  are  pro- 
duced which  cause  coagulation  in  the  blood-serum  which  comes  in 
contact  with  the  necrotic  tissue. 

A  new  theory  of  coagulation   has  been   advanced   by   Arthur  and 
Pages.     These  observers  found  that  if  a  certain  proi>ortion  of  oxalate 


'  &^ 


of  potash  be  added  to  freshly-drawn  blood,  it  loses  its  jiower  of  coagula- 
tion. They  attribute  the  action  of  the  oxalate  to  the  precipitation  from 
the  blood  of  the  soluble  lime-salts  which  it  contains.  If  a  solution  of 
chloride  of  lime  be  added  to  the  blood  containing  the  oxalate,  coagula- 
tion will  take  place.  No  matter  how  long  the  oxalatcd  blood  may  be 
kept,  it  will  remain  fluid,  and  coagulation  will  take  ])lace  as  soon  as  the 
lime-salts  are  driven  from  their  connection  with  the  oxalate  and  again 
set  free  in  the  fluid.  The  fibrin-ferment  only  acts  on  the  filirinogen, 
converting  it  into  fibrin  when  lime  is  present.  In  coagulation  the 
fibrinogen  undergoes  a  chemical  change  by  M'hich  it  is  converted  into 
fibrin,  the  fibrin  being  a  union  of  lime-salts  and  albumin. 

The  coagulation  of  the  blood  in  the  vessels  during  life  is  jirevcnted 
by  some  action  exerted  on  the  blood  by  the  living  endothelium  of  the 
blood-vessels.  The  blood  contains  the  necessary  element  for  coagula- 
tion, and  a  certain  amount  of  fibrin-ferment  must  be  constantly  pro- 
duced by  the  disintegration  of  leucocytes  and  other  cells,  which  to  some 
extent  is  always  going  on.  In  inflammatory  exudations  and  in  the 
necrosis  of  the  tissues  fibrin-ferment  is  certain!}-  present,  and  being 
soluljle  it  must  enter  into  the  circulation.  If  a  large  vein  of  an  animal 
be  carefully  ligated  and  removed  from  the  body  while  filled  with  blood, 
coagulation  of  the  blood  contained  in  this  receptacle  does  not  take  place 
for  a  long  time,  and  when  it  does  the  clot  is  always  thinner  than  when 
formed  under  ordinary  circumstances.  The  serous  tissues  act  in  the 
same  way  in  preventing  coagulation.  If  small  vessels  are  included 
between  doul^le  ligatures,  care  being  taken  to  pre\'ent  any  injury  to  the 
vessel  by  the  ligature,  tlie  blood  in  the  vessels  will  not  coagulate.  Stag- 
nation of  the  blood  in  the  absence  of  other  factors  will  not  produce 
coagidation  in  the  vessels,  but  it  will  fiivor  it.  If  the  wall  of  the  blood- 
vessel is  injured  in  any  way,  thrombi  will  be  formed  on  the  injured  sur- 
face. It  is  not  known  to  what  this  action  of  the  living  endothelium  in 
preventing  coagulation  of  the  lilood  is  due.  It  is  not  due  to  the  smooth- 
ness of  the  surface  alone,  for  N'irciiow  has  shown  that  thrombi  will 
foi'm  around  globules  of  quicksilver  when  they  are  brought  into  the 


THROMBOSIS  AND  EMBOLISM.  207 

circulation.  It  is  probable  that  the  prevention  of  coagulation  is  a 
property  of  the  living  endothelial  cells.  The  endothelial  cells  do  not 
simply  provide  a  physical  lining  to  the  vessels,  but  have  as  definite  prop- 
erties as  gland-cells,  and  they  may  produce  substances  which  oppose  the 
action  of  the  fibrin-ferment. 

Coagulation  of  the  lilood  takes  place  in  the  vessels  a  few  hours 
after  death.  Certain  conditions  favor  or  oppose  the  post-mortem  coagu- 
lation. An  excess  of  carbonic  acid  in  the  blood  retards  the  coagula- 
tion, and  in  death  after  sufibcation  the  blood  is  usually  found  fiuid. 
The  l)]ood  is  fluid,  or  clots  feebly,  after  death  from  certain  poisons 
and  from  a  number  of  infectious  diseases,  especially  those  due  to  the 
absorjjtion  of  chemical  bacterial  poisons.  The  blood  is  firmly  clotted 
after  death  from  pneumonia,  in  which  disease  the  fibrin-ferment  in  the 
blood  is  increased.  The  clot  found  in  the  vessels  may  resemble  the  clot 
formed  outside  of  the  body,  or  in  certain  places,  notably  in  the  heart, 
clots  are  formed  wliich  are  colorless  and  transparent,  and  resemlde  the 
clot  obtained  by  whipping  the  blood  and  gatiiering  tiie  fibrin.  Clots  of 
this  sort  are  not  strictly  ])ost-mortcm.  For  their  formation  a  certain 
amount  of  motion  in  the  blood  is  necessary,  and  it  is  probable  that  tliey 
form  in  the  last  minutes  of  life,  especially  under  circumstances  in  which 
the  power  of  coagulation  is  increased,  as  in  crou])ous  pneumonia. 

Three  principal  varieties  of  thrombi  may  be  distinguished,  and  there 
are  various  intermediate  stages.  The  white  thrombus  is  of  firm  con- 
sistency and  has  a  grayish,  and  sometimes  a  yellowish-white,  appearance. 
On  microscopic  examination  it  is  principally  composed  of  white  corpus- 
cles and  fibrin.  Many  of  the  white  corpuscles  are  apparently  normal 
and  their  nuclei  stain  clearly  ;  others  show  every  stage  of  disintegration. 
The  fil)rin  appears  either  in  the  form  of  very  minute  filaments,  forming 
a  meshwork  and  enclosing  the  leucocytes  in  its  meshes,  or  the  filaments 
may  be  large  and  coarse.  At  times  the  thrombus  has  a  hj-aline,  more 
transparent  appearance,  and  this  is  due  to  the  presence  in  it  of  large 
masses  of  hyaline  material  which  stain  in  the  same  way  as  fibrin,  and  which 
probal)ly  result  from  a  hyaline  metamorphosis  of  the  fibrin.  In  many 
cases  the  fibrin  is  arranged  in  definite  layers  which  may  be  stripped  off. 
This  is  especially  the  case  in  the  large  thrombi  formed  in  aneurisms. 
The  whole  space  of  the  aneurism  is  frequently  filled  with  lamelhe  of 
fibrin.  Along  with  the  leucocytes  and  fibrin  a  certain  nunilier  of  red 
corpuscles  are  generally  found,  and  a  quantity  of  granular  material, 
which  may  result  from  disintegration  of  the  fii)rin  or  white  corpuscles, 
or  may  have  another  origin. 

The  red  thrombus  is  less  firm  than  the  white.  The  red  color  is  due 
to  a  greater  numlier  of  red  corpuscles,  or  pigment  resulting  from  their 
disintegration,  entangled  in  the  meshes  of  the  fibrin.  The  red  thrombus 
shows  various  degrees  of  color,  depending  upon  the  amount  of  blood- 
pigment  in  it,  and  is  formed  more  rapidly  than  the  white. 

In  the  mixed  thrombus  there  is  a  combination  of  both  forms.  It 
frequently  has  an  excjuisitely  lamellated  structure,  a  red  lamella  follow- 
ing a  white  in  regular  order.  This  mixture  of  the  two  colors  is  due  to 
an  alternation  of  rapid  and  slo«-  coagulation  on  the  surface. 

The  consistency  of  the  thrombus  may  differ  in  different  parts.  We 
can  frequently  distinguish  a  firmer  portion  of  tiie  thrombus  to  which 


208  SURGICAL  PATHOLOGY. 

tlie  romaiiuler  is  loosely  attai-liwl.  Tlio  firm  jwrtion  is  the  true  tlironi- 
I)iis,  which  is  clue  to  the  loeal  ciuise,  and  tiie  other  is  simply  a  eoa<;ulum 
fdrmed  on  this.  The  soft  red  cnaLiidmii  may  extend  t'nun  tlie  thrombus 
a  considerable  distance  in  tiie  blood-current,  and  is  called  the  sec(m(lary 
or  continued  thrombus.  When  a  vessel  is  completely  occluded  the 
thrombus  extends  up  to  the  next  branch  entering  or  given  oif  from 
the  thrombosed   vessel. 

True  thrombi  may  l)e  distinguished  from  post-mortem  coagula  in 
a  number  of  ways.  Thrombi  are  more  consistent  than  post-mortem 
clots;  they  are  more  adherent  to  the  walls  of  the  vessels.  The  adhesion 
is  due  to  several  causes.  If  the  thrombus  be  sufficiently  old  and  if 
organization  has  taken  place  in  it,  there  is  a  definite  tissue-union  between 
the  thrombus  and  the  vessel-wall.  Even  if  there  is  not  formation  of 
tissue  extending  from  the  wall  of  the  vessel  into  the  thrombus,  there  is 
frequently  a  formation  of  fibrin  in  the  wall  of  the  vessel  which  unites 
with  the  fibrin  of  the  thrombus. 

The  thrombus  may  occupy  various  relations  to  the  lumen  of  the 
vessel.  It  may  fill  up  the  entire  vessel  or  occupy  only  a  small  portion 
of  the  wall,  allowing  the  blood-current  to  flow  past  it.  As  a  rule, 
thrombi  are  formed  by  coagulation  over  a  small  area  of  the  wall  of  the 
vessel,  and  then  successive  coagula  are  formed  on  the  first.  In  the  heart 
these  successive  coagula  may  be  formed  until  a  large  mass  ]irojecting 
like  a  polypus  into  one  of  the  cavities  of  the  heart  is  produced. 

Another  variety  of  thrombus  is  due  to  aggregations  of  the  blood- 
plates.  There  is  still  much  contention  about  these  blood-plates  and  the 
part  which  they  play  in  coagulation  and  thrombus-formation.  It  is 
held,  on  the  one  hand,  that  they  are  essential  constituents  of  the  l)lood, 
and  on  the  other  that  they  result  from  the  disintegration  of  white  cor- 
puscles. Eberth  and  Schimmclbusch,  in  studying  the  experimental 
formation  of  thrombi,  found  that  the  first  appearance  of  the  white 
thrombus  was  due  to  a  collection  of  these  blood-plates.  They  form 
with  the  greatest  rapidity  just  at  the  point  where  the  vessel  is  injured. 
They  call  the  thrombus  so  formed  the  blood-plate  thrombus.  Welch 
has  also  found  that  thrombi  which  at  first  are  entirely  composed  of 
blood-plates  can  be  produced  exjjerimcntally  by  slight  injuries  of  the 
wall  of  a  blood-vessel,  and  it  hardly  seems  probable  that  all  the  leuco- 
cytes which  had  collected  at  such  a  place  could  have  broken  down. 
Weigert  does  not  consider  these  aggregations  of  l)lood-plates  as  true 
thrombi.  He  considers  the  thrombus  a  true  coagulation  of  the  blood, 
and  not  an  aggregation  of  some  of  its  constituents.  A  consitlerable 
amount  of  granular  material  which  is  found  in  the  thrombus  may  be 
composed  of  these  blood-plates.  Zahn  studied  the  formation  of  thrombi 
in  the  veins  of  the  mesentery  of  a  curarized  frog  directly  under  the 
microscope.  He  found  that  -when  a  crystal  of  salt  was  placed  in  con- 
tact with  the  vein  the  first  change  noticed  was  a  collection  of  leucocytes 
at  the  point.  Finally,  the  entire  lumen  of  the  vessel  was  occluded  by 
the  leucocytes.  In  the  course  of  some  hours  the  thrombus  underwent 
important  changes.  The  white  corpuscles  lost  their  form  and  regular 
contours,  and  became  changed  into  a  more  or  less  finely  granular  mass, 
and  then  fibi'in-filaments  appeared. 

Both  local  and  general  conditions  favor  the  formation  of  thrombi. 


THROMBOSIS  AND  EMBOLISM.  209 

The  local  conditions  favoring  their  formation  are  stagnation  of  the  blood 
and  changes  or  injuries  in  the  lining  membranes  of  the  vessels.  Exper- 
imentally, it  seems  to  be  shown  that  when  the  l)lood  is  enclosed  in  a  vessel 
between  double  ligatures  coagulation  will  not  take  place  if  the  vessels 
be  ligated  so  carefully  that  all  injury  to  the  wall  is  prevented.  Even 
if  \ve  suppose  that  a  lesion  of  the  endothelium  is  necessary  for  coagu- 
lation, such  a  lesion  may  be  produced  by  stagnation  of  the  blood. 
The  endcjthelium  of  the  blood-vessels  is  nourished  by  the  blood,  and 
not  only  the  blood,  but  its  constant  renewal,  is  necessary,  and  a  loss  of 
function  of  the  endothelium  due  to  lack  of  nutrition  would  suffice  to 
produce  coagulation.  As  a  rule,  the  smaller  the  blood-vessel  in  which 
stagnation  takes  place,  the  less  likelihood  is  there  of  coagulation.  The 
larger  the  area  of  blood  relatively  to  its  mass  ^vhich  comes  in  contact 
Avitli  the  endothelium,  the  less  readily  will  coagulation  take  place.  In  a 
small  vessel  degeneration  of  the  endothelium  would  not  be  so  likely  to 
take  place,  because  it  could  more  readily  be  nourished  by  imbibition 
from  the  surrounding  tissues.  The  thrombi  produced  by  stagnation  of 
the  blood  are  formed  first  in  the  pockets  behind  the  valves,  where  the 
stagnation  is  most  complete.  Thrombi  may  form  around  foreign  bodies, 
but  there  is  little  opportunity  given  for  this  mode  of  formation  in  man. 

Virchow  first  called  attention  to  the  jiart  which  alterations  in  the  walls 
of  the  blood-vessels  play  in  tlie  formation  of  thrombi,  and  regarded  the 
coagulation  as  the  result  of  altered  molecular  attraction  between  the  wall  of 
the  vessel  and  the  blood.  Ulceration,  inflammation,  necrosis,  and  various 
other  pathological  conditions  in  the  neighborhood  of  blood-vessels  may 
so  atfect  their  walls  as  to  lead  to  thrombosis.  Frequently  the  coagula- 
tion which  takes  place  under  such  circumstances  is  essentially  a  con- 
servative process,  and  the  hemorrhage  which  would  otherwise  follow 
the  extension  of  the  ulceration  into  a  large  vessel  is  avoided.  Dilata- 
tions of  vessels  favor  the  formation  of  thrombi.  The  thrombus  forms  the 
more  easily  the  more  sharply  circumscribed  and  the  more  partial  the 
dilatations  are.  In  such  conditions,  of  which  the  best  type  is  given  in 
aneurism,  the  thrombosis  is  further  assisted  l)y  calcification  and  various 
degenerations  of  the  lining  wall  of  the  aneurism. 

Various  conditions  of  the  system  favor  the  formation  of  thrombi. 
They  are  frequently  found  in  ^veak  marantic  individuals,  particularly 
when  they  have  had  long-continued  supjiuration.  In  such  individuals 
thrombi  are  frequently  found  in  the  pockets  behind  the  valves  of  the 
veins,  in  the  sinuses  of  the  dura  mater,  and  in  tlic  auricular  appendages 
and  between  the  muscular  trabccuhe  of  tlie  licart.  Virchow  considered 
the  essential  factor  in  the  production  of  sucli  thrombi  the  weakness  of 
the  heart  and  circulation.  Even  in  such  conditions  the  thrombosis  may 
be  favored  by  local  .degenerations  of  the  endothelium.  The  nutrition 
of  the  vessels  will  suffer  in  consequence  of  the  diminution  in  the  gen- 
eral nutritive  power  of  the  blood  and  the  diminution  in  its  rapidity  of 
flow.  Tiiese  conditions  will  be  felt  most  where  local  conditions  favoring 
stagnation  are  present. 

There  may  be  certain  chemical  alterations  in  the  blood  which  increase 
its  coagulability.  The  injection  into  the  blood  of  the  extracts  of  certain 
glands,  especially  of  the  thymus  gland,  increases  its  coagulability. 
Extracts    of    htemoglobin,    especially    the    hsemoglobin    derived    from 

Vol.  I.— U 


210  SURGICAL  PATirOLOGY. 

a  different  animal,  lias  the  same  effeet.  There  were  numennis  ex- 
amj)l(>s  of  this  when  the  blood  of  different  animals  was  used  for  trans- 
fusion. Under  such  circumstances  death  frequently  occurred  shortly 
after  tlie  transfusion,  and  at  the  autopsy  extensive  thrombosis  was  found. 
In  certain  cases  tlicre  may  be  such  extensive  thrombosis  in  the  vessels 
that  the  existence  of  substances  in  the  blood  \\hich  materially  increase 
its  power  of  coagulation  must  be  assumed.  These  are  cases  in  M'hich 
in  a  very  short  time,  and  apparently  without  any  lesions  in  the  walls  of 
the  vessels,  there  is  extensive  formation  of  thrombi.  It  is  possible  that 
substances  may  be  formed  in  certain  organs  of  the  body,  and  may  have 
a  local  influence  in  assisting  thrombosis.  There  mav  be  extensive 
thrombosis,  especially  in  the  very  smallest  veins  and  capillaries,  which 
occurs  in  the  course  of  certain  infectious  diseases.  The  thrombi  formed 
under  these  circumstances  are  different  from  the  ordinary  thrombi,  being 
composed  almost  entirely  of  hyaline  material.  Such  thrombi  are  fre- 
quently found  in  vessels  of  thi'  kidney  and  the  lungs. 

The  thromlius  when  once  formed  nndergoes  various  changes.  It 
contracts  and  l)ecomes  firmer  and  harder.  Softening  frequently  takes 
place,  especially  in  large  thrombi  formed  in  the  heart  and  large  vessels. 
The  thrombus  becomes  converted  into  a  soft  pulpy  mass  of  an  opaque 
granular  appearance  closely  resembling  pus.  The  softening  most  fre- 
quently takes  place  in  the  centre  of  the  thnmibus.  In  the  softened 
material  of  the  thrombus  there  is  a  quantity  of  fatty  granular  material 
M'hich  is  derived  from  tlie  breaking  dt)wn  of  Ijoth  the  cells  and  the 
fibrin.  The  fluid  in  the  centre  is  frequently  surrounded  by  a  dense 
outside  wall.  The  fluid  results  both  from  the  absorjrtion  of  fluid  from 
the  blood  and  the  contraction  of  the  thrombus.  This  softening  may 
take  place  until  the  thrombus  resembles  a  cyst  filled  with  fluid.  The 
thrombus  may  become  organized  and  converted  into  a  mass  of  connec- 
tive tissue.  The  manner  in  which  the  organization  of  the  thrombus 
takes  place  has  been  the  subject  of  a  great  deal  of  dispute  among  path- 
ologists, and  the  study  of  the  jirocess  has  led  to  a  material  increase  of 
our  knowledge  about  this  and  tiie  formation  of  pathological  connective 
tissue  in  general.  It  was  at  first  supposed  that  tlie  connective  tissue  in 
the  thrombus  was  formed  by  a  direct  conversion  of  the  constituents  of 
the  thrombus  into  connective  tissue.  It  is  now  known  that  the  organ- 
ization of  the  thrombus  is  due  to  a  growth  of  connective  tissue  into 
it  from  the  wall  of  the  blood-vessel.  It  is  not  probable  that  the  white 
corpuscles  in  the  thrombus  itself  take  any  part  at  all  in  the  organization. 
In  the  first  stages  of  the  organization  of  the  thromlius  it  becomes  filled 
with  leucocytes  which  are  derived  from  the  wall  of  the  blood-vessels. 
In  some  cases  it  seems  probable  that  there  may  l)e  an  invasion  of  the 
thrombus  by  leucocytes  Avhicli  are  derived  from  the  blood  itself.  After 
the  leucocytes,  and  along  with  them,  large  epithelioid  cells  appear  which 
are  derived  from  the  M'alls  of  the  vessels.  These  cells  are  accompa- 
nied by  a  new  formation  of  blood-vessels  proceeding  from  the  adjacent 
blood-vessels  of  the  tissue,  and  a  new  formation  of  connective  tissue 
takes  place  from  the  large  epithelioid  cells.  The  leucocytes  ajipear  to 
prejiare  the  way  for  the  after-formation  of  tissue,  and,  as  in  the  connec- 
tive-tissue formation  in  inflammation,  it  is  jirobable  that  they  to  some 
extent  furnish  food  for  the  growing  cells.     The  thrombus  in  the  course 


THROMBOSIS  AND  EMBOLISM.  211 

of  organization  becomes  filled  with  large  dilated  blood-vessels  that  fre- 
quently conmuinieate  with  one  another.  Under  favorable  circumstances 
communications  may  be  formed  between  the  blood-vessels  of  the  throm- 
bus and  the  lumen  of  the  vessel,  and  in  this  way  the  continuity  of  the 
lumen  of  the  vessel  may  be  again  accomplished.  The  red  thrombus  in 
the  course  of  time  becomes  decolorized  and  converted  into  a  yellowish 
or  yellowish-brown  material.  The  thrombus  may  become  calcified,  and, 
in  consequence  of  this,  becomes  converted  into  a  hard,  calcareous  mass. 
The  so-called  vein-stones,  or  phleboliths,  are  due  to  calcification  of 
thrombi.  The  calcification  is  due  to  the  deposition  of  lime-salts  in  the 
thrombus.  All  of  these  changes  in  the  thrombus  are  relatively  favor- 
able. Other  changes  are  not  so  favoralile.  There  may  be  an  actual 
purulent  softening  of  the  thrombus.  When  there  is  purulent  inflam- 
mation in  the  tissues  around  the  tin-oml)osed  vessel  the  suppuration 
may  extend  to  the  blood-vessel  and  into  the  thrombus.  Not  onl\-  may 
the  pus-cells  M'ander  from  the  vasa  vasorum  and  enter  the  blood-vessel 
and  thrombus,  Init  the  pyogenic  bacteria  may  also  be  carried  by  these. 
Under  such  circumstances  no  organization  of  the  thrombus  takes  place, 
and  it  becomes  converted  into  a  soft  friable  mass. 

Embolism. 

Although  the  thrombi  may  produce  both  local  and  general  effects  on 
the  circulation,  these  are  not  the  chief  dangers  which  result  from  them. 
In  many  cases  the  thrombus  docs  not  entirely  obstruct  the  wall  of  the 
vessel,  and  the  blood  circulates  in  the  vessel  beyond  the  thrombus. 
Even  when  the  thrombus  completely  occludes  the  vessel,  it  extends  up 
to  the  next  collateral  branch,  and  frequently  beyond  this,  so  that  a  por- 
tion extends  into  a  vessel  where  the  circulation  is  still  taking  place.  The 
tin'ombi,  further,  are  more  frequently  found  in  the  \'enous  side  of  the 
circulation  than  in  the  arterial.  The  chief  danger  from  the  thrombi  is 
that  portions  may  be  Mashed  off,  carried  into  the  circulating  blood,  and 
finally  occlude  arteries.  The  thi'ombi  being  more  frequent  in  the  venous 
system,  the  particles  Mhich  are  washed  off  from  them  occlude  the  ves- 
sels of  the  lungs.  When  thrombi  are  formed  in  the  left  side  of  the 
lieart  and  in  the  arterial  system  generally,  they  M'ill  be  carried  into  some 
other  part  of  the  circulation.  The  particles  of  the  thrombus  which 
nray  be  broken  off  and  enter  into  the  blood-stream  vary  in  size.  The 
largest  pieces  come  from  the  thrombi  formed  in  aneurisms,  from  the 
heart-cavities,  and  from  the  large  veins.  These  portions  of  the  throm- 
bus which  are  carried  by  the  blood-current  to  another  portion  of  the 
body  arc  called  I'lnholi.  Where  they  will  lodge  depends  upon  the  posi- 
tion of  the  thrombus.  If  they  come  from  the  veins,  they  will  enter 
into  the  pulmonary  a'rteries.  Those  from  the  arterial  side — that  is,  from 
the  left  heart,  the  systemic  arteries,  and  the  lung-veins — are  carried 
into  the  systemic  arterial  system,  and  those  from  branches  of  the  jiortal 
vein  into  the  branches  of  the  portal  vein  within  the  liver.  These 
emboli  will  be  carried  along  by  the  blood-stream,  and  finally  stop  where 
the  calibre  of  the  blood-vessels  is  smaller  than  the  diameter  of  the  emboli. 
Virchow,  and  especially  Recklinghausen,  have  called  attention  to  the  fact 
that  there  may  be  a  transportation  of  thrombi  in  a  direction  contrary  to 


212  SURGICAL  PATHOLOGY. 

tilt'  blood-stream.  It  is  difficult  to  sec  liow  this  takes  place.  It  may  be 
assisted  by  gravity,  and  it  can  only  take  place  in  parts  where  the  circu- 
lation is  exceedingly  feeble  and  the  ])lood-pressure  in  the  veins  very  low. 
Large  emboli  can  occlude  the  chief  branches  of  the  pulmonary  arteries, 
or  on  the  arterial  side  may  occlude  large  arteries,  such  as  the  renal  or 
iliac,  or  even  the  descending  aorta.  The  smallest  emboli  may  enter  into 
the  capillaries,  and  where  the  cajiillaries  are  relatively  wide,  as  in  the 
lungs,  they  may  pass  through  tlicsc,  and  afterward  plug  up  the  narrower 
capillaries  of  the  systemic  circulation.  It  is  evident  tliat  solid  particles 
whose  diameter  is  smaller  than  the  capillaries  can  pass  unliindercd  tiirough 
all  parts  of  the  circulation.  The  emboli  are  apt  to  bo  found  in  places 
where  the  lumen  of  the  vessel  undergoes  a  sudden  diminution  in  size, 
especially  where  large  branches  are  given  off. 

It  is  not  uncommon  to  find  emboli  entering  into  each  l)ranch  of  an 
artery  at  the  place  of  its  bifurcation.  Such  emboli  are  sj)oken  of  as 
riding  emboli,  situated  as  they  are  at  the  place  of  bifurcation,  as  in  a 
saddle,  with  one  leg  in  each  division  of  the  artery.  The  emboli  almost 
always  produce  total  occlusion  of  the  vessel  where  they  are  found.  They 
are  carried  with  some  force  into  the  vessel,  and  being  comparatively  soft 
they  will  lie  pressed  into  it  mitil  they  totally  occlude  it.  The  emboli 
may  undergo  the  same  changes  as  thrombi.  They  can  become  softened 
or  they  may  organize. 

There  may  be  special  varieties  of  emboli  ^\'liich  arc  not  due  to 
thrombi,  but  which  are  due  to  substances  accidentally  introduced  into 
the  vessels.  Under  certain  conditions  either  air  or  a  fluid  which  will 
not  readily  pass  through  the  ca])illarics,  such  as  oil,  may  be  introduced 
into  the  circulation.  A  large  number  of  cases  have  been  reported  of 
death  in  human  beings  attributed  to  the  entrance  of  air  into  the  veins. 
This  accident  has  generally  happened  in  surgical  cases  where  operations 
have  been  done  about  the  neck,  shoulders,  and  skull.  Further,  death 
has  occurred  in  cases  in  which  air  has  entered  the  sinuses  of  the  puer- 
peral uterus,  generally  in  cases  of  criminal  abortion  in  which  air  has 
been  injected  into  the  uterine  cavity.  In  some  of  these  cases  death  has 
been  instantaneous,  and  in  these  there  seems  to  be  no  reason  to  doubt 
that  it  has  been  due  to  the  entrance  of  air  into  the  circulation  and  the 
stoppage  of  large  areas  of  the  vascular  territory  of  the  lungs.  A  con- 
siderable amount  of  doubt,  however,  has  been  thrown  on  such  cases  by 
the  result  of  experiment.  It  has  been  shown  that  the  amount  of  air 
which  is  required  to  kill  a  dog  if  the  air  is  directly  injected  into  the 
vessels  is  much  greater  than  could  possibly  enter  the  vessels  in  a  sur- 
gical o]>eration.  If  the  air  is  injected  slowly,  enormous  amounts  can  be 
injected  without  producing  anything  more  than  slight  disturbances  of 
the  respiration  and  the  action  of  the  heart.  In  the  cases  in  Avhich  death 
has  been  attributed  to  the  entrance  of  air  into  the  veins  a  large  quan- 
tity of  air  or  gas  is  found  in  the  blood-vessels  after  death.  Welch  has 
shown  that  this  is  frequently  due  to  the  growth  of  an  aeroliic  gas-pro- 
ducing bacillus  in  the  blood.  There  is  no  doubt  that  a  number  of  the 
cases  which  have  been  reported  of  death  from  air-embolism,  in  which 
death  has  taken  place  some  time  after  the  supposed  entrance  of  air,  have 
been  due  to  infection  with  this  bacillus,  but  there  is  equally  no  doubt 
that  there  have  been  cases  of  sudden  death  due  to  the  entrance  of  not 


THROMBOSIS  AND  EMBOLISM.  213 

very  large  quantities  of  air  into  the  circulation.  The  air  is  especially 
apt  to  enter  into  the  veins  if  there  is  an  inspiration  at  the  same  moment 
when  a  largo  vein,  such  as  the  jugular,  is  opened.  When  a  large  amount 
of  air  enters  the  heart  at  one  time,  death  may  ([uickly  take  place  with 
evidences  of  sutfocation.  This  is  due  to  collection  of  air  in  the  heart. 
The  air  is  not  forced  out  of  the  heart  at  each  contraction  of  the  ven- 
tricle, but  is  simply  compressed.  When  a  small  amount  of  air  enters 
slowly  it  will  enter  into  the  circulation,  and  may  produce  temporary 
occlusion  of  a  number  of  the  capillaries  in  the  lungs.  Unless  the  vas- 
cular territory  so  occluded  is  very  large  there  will  be  little  inconvenience, 
because  the  air  will  gradually  be  forced  through  the  capillaries  by  sub- 
sequent contraction  of  the  heart,  and  in  a  short  while  most  of  it  will 
become  absorbed. 

The  presence  of  fat-emboli  in  the  vessels  of  the  lung  has  attracted 
considerable  attention,  but  the  importance  of  these  emboli  has  been  very 
greatly  over-estimated.  The  fat  of  tlie  l)ody  is  in  a  fluid  condition  dur- 
ing life,  the  fat-cell  representing  a  drop  of  fluid  oil  enclosed  in  a  vesicle. 
Wiien  a  number  of  these  vesicles  are  broken,  as  in  extensive  crushing 
injuries,  and  the  veins  are  ruptured  at  the  same  time,  a  certain  amount 
of  this  fluid  fat  can  enter  into  the  circulation.  It  is  especially  apt  to  do 
this  in  injuries  of  the  bones  where  there  is  not  only  a  large  amount  of 
fat  in  the  marrow,  but  where  the  veins  are  large  and  do  not  collapse. 
The  fat  entering  the  circulation  in  this  way  is  nearly  all  stopped  in  the 
capillaries  of  the  lungs,  and  may  be  found  there  at  autopsies.  It  was 
at  one  time  supposed  that  the  shock  after  severe  surgical  injuries  could 
be  in  large  part  explained  by  fat-embolism.  It  is  rare,  however,  that 
the  fat  is  jireseut  in  sufficient  amount  to  produce  any  serious  results  by 
occlusion  of  the  capillaries.  The  collateral  circulation  in  the  capillaries 
is  so  abundant  that  no  result  can  take  place  from  the  occlusion  of  a  few. 
It  is  only  when  all  of  the  capillaries  of  a  very  large  area  are  occluded 
that  any  results  will  follow. 

The  General  and  Local  Effects  of  Thrombi  and  Emboli. 

An  occluding  thrombus  in  any  portion  of  the  venous  system  will  lead 
to  congestion  and  increased  venous  pressure  in  the  vein  behind  the 
thrombus.  The  severity  of  the  changes  produced  will  depend  upon  the 
local  conditions  of  the  circulation  in  the  part  and  the  size  of  the  vessel. 
If  a  large  vein  be  occluded,  it  is  evident  that  the  consequences  will 
be  more  serious  than  if  the  vein  l^e  a  small  one.  Local  conditions 
of  the  circulation  aftecting  the  results  produced  by  a  thrombus  are 
due  to  the  abundanc.e  or  absence  of  collaterals.  When  there  are  two 
veins  leading  from  a  part  with  "an  abundant  anastomosis  between  their 
branches,  the  occlusion  of  one  of  tliem  will  have  no  eifect.  The  rapidity 
witli  wiiich  the  thrombus  is  formed  will  also  influence  the  result.  If  the 
renal  vein  be  ligated,  intense  passive  congestion  of  the  kidney  with  hem- 
orrhage and  necrosis  results.  Com])lete  occlusion  of  the  renal  vein  by 
a  thrombus  is  sometimes  seen  without  producing  any  results.  The 
thrombus  is  formed  slowly,  and  time  is  given  for  the  dilatation  of  the 
vessels  of  the  collateral  venous  circulation,  so  that  by  the  time  the  occlu- 
sion is  complete  these  vessels  are  sufficiently  dilated  to  carry  off  all  the 


214  SURGICAL  PATHOLOGY. 

blood  fnini  the  kidney.  Tlic  same  tiling  is  true  of  the  portal  vein. 
AVhen  thi.s  is  ligated  death  results  from  the  enormous  distention  of  its 
branc^hes.  When  it  is  slowly  oeeluded  by  means  of  thrombus-forma- 
tion the  few  collateral  brancdies  dilate  sufficiently  to  carry  off  the  main 
portion  of  the  blood,  although  the  collateral  circulation  is  rarely  suf- 
ficient to  prevent  ascites  and  passive  congestion.  Sudden  occlusion  of 
the  femoral  vein  in  the  neighboriiood  of  Poupart's  ligament  is  usually 
fiital.  Intense  congestion,  eedema,  and  gangrene  of  the  entire  leg- 
develop.  When  the  occlusion  takes  2)lace  gradually  by  the  slow  forma- 
tion of  a  thrombus  or  by  pressure  of  a  tumor,  no  unfavorable  conditions 
other  than  oedema  to  a  greater  or  less  degree  may  develop. 

The  local  effects  of  an  embolus  will  depend  to  a  certain  degree  upon 
the  physical  character  of  the  emljolus.  Virchow  found  that  when  hard 
substances,  especially  those  with  irregular  walls,  were  introduced  into 
the  cii'culation,  they  produced  intense  inflammation,  frequently  with  rup- 
ture of  the  vessel  at  the  point  where  they  were  arrested.  Wherev^er  an 
embolus  lodges  and  whatever  its  character,  it  Avill  al\\ays  ])roduce 
ciianges  in  the  wall  of  the  vessel  in  contact  with  it.  The  endothelium 
will  become  necrotic,  and  the  necrosis  may  extend  some  distance  into  the 
surrounding  tissue.  Other  local  changes  may  be  produced  which  do  not 
depend  upon  the  physical  characters  of  the  embolus,  but  upon  its  biologi- 
cal characters.  The  embolus  may  consist  of  living  tissue,  which  may 
grow  where  it  lodges.  Particles  of  tumor  are  frequently  carried  by  the 
circulation  from  a  primary  focus  to  a  distant  organ,  and  develop,  forming 
secondary  tumors  where  they  lodge.  Not  only  particles  of  living  tissue, 
but  living  organisms,  may  be  contained  in  the  embolus,  and  these  will 
produce  the  same  lesions  as  in  the  place  from  which  they  were  derived. 
This  is  especially  seen  in  the  emboli  which  come  from  the  purulent  soft- 
ening of  a  thrombus.  In  this  way  a  secondary  abscess  may  be  formed 
around  an  embolus. 

The  occlusion  of  an  artery  will  jtroduce  effects  in  the  tissue  supplied 
by  it.  Here  the  effects  produced  will  depend  upon  the  presence  or 
absence  of  collateral  branches  going  to  the  same  tissue.  In  certain 
parts  of  the  body  definite  areas  of  tissue  are  supplied  by  definite 
arteries  without  anastomoses.  Such  terminal  arteries  are  found  in  the 
kidneys,  heart,  and  other  organs.  Tiie  effect  produced  will  also  dci)end 
upon  the  size  of  the  artery. "  The  collateral  circulation  may  suffice  for  a 
small  area,  but  not  for  a  large  one.  There  may  be  prculuccd  by  the 
occlusion  of  an  artery  two  conditions  which  are  apparently  widely  dif- 
ferent. If  the  artery  be  a  terminal  one,  the  tissue  supplied  by  it  becomes 
necrotic.  The  form  of  necrosis  produced  is  that  described  by  Weigert 
as  coagulation-necrosis,  in  which  there  is  necrosis  of  the  cells  with 
coagulation.  The  anremic  part  has  a  whitish,  opaque  character,  and  is 
generally  triangular  in  shape,  the  ajiex  of  the  triangle  being  formed  by 
the  occluded  artery.  Or  a  hemorrhagic  infarction  may  be  produced.  In 
some  cases  hemorrhage  takes  place  into  the  previous  anajmic  territory. 
The  source  of  the  blood  in  this  case  has  been  a  matter  of  dispute. 
Cohnheim  supposed  that  it  was  due  to  a  backward  flow  from  tlie  veins, 
but  this  can  be  shown  to  be  erroneous,  because  the  infiirction  takes  place 
Avhen  the  veins  are  tied  at  the  same  time  \\ith  the  artery.  The  blood 
may  have  various  sources.     It  is  impossible  by  arterial  occlusion  to  shut 


HYPERTROPHY  AND  REGENERATION.  215 

oft'  all  blood  from  a  part.  There  are  always  anastomoses  with  the  capil- 
laries of  a  neighboring  part,  and  if  the  ansemic  area  be  very  small  the 
capillary  anastomoses  will  be  sufficient  to  preserve  the  life  of  the  tissues. 
The  first  effect  of  arterial  occlusion  must  be  to  lower  the  pressure  in  the 
circulation  distal  to  the  occlusion.  The  pressure  will  be  lower  in  all  the 
vessels  of  the  part,  and  the  blood  will  ffow  into  it  from  all  the  adjacent 
vessels.  The  blood-vessels  become  distended  and  diapedesis  of  red  cor- 
puscles takes  place.  If  the  amount  of  Idood  entering  the  vessels  of  the 
part  is  not  sufficient  to  provide  ibr  a  regular  circulation,  all  of  the  tissue 
becomes  necrotic.  The  diapedesis  is  generally  supposed  to  be  due  to 
nutritive  changes  in  the  walls  of  the  vessels,  but  it  may  Ite  the  result  of 
changes  which  ha\'e  taken  place  in  the  character  of  the  blood.  A  comljina- 
tion  is  frequently  seen  between  hemorrhagic  and  ansemic  infarctions.  The 
centre  of  the  infarction  may  be  white  and  anremic  and  be  surrounded 
by  a  hemorrliagic  zone.  In  this  case  sufficient  Ithiod  ddcs  not  enter  the 
vessels  to  penetrate  to  the  centre,  or  necrosis  with  coagulation  may  take 
place  before  it  has  sufficient  time  to  do  so.  Various  conditions  of  the 
body  may  influence  the  effects  jjroduccd  by  an  embolism.  If  the  circu- 
lation is  feeble  and  the  general  state  of  nutrition  poor,  the  effect  will  be 
more  disastrous.  Embolism  of  the  pulmonary  arteries,  unless  the  vessel 
be  of  considerable  size,  may  not  produce  any  effects.  In  the  ordinary 
conditions  of  the  pulmonary  circulation  there  is  sufficient  ca])illary 
anastomosis,  assisted  by  the  anastomoses  of  the  bronchial  artery,  to  pre- 
serve the  life  of  the  tissue.  In  any  embarrassment  of  the  pulmonary  cir- 
culation, especially  in  chronic  passive  congestion,  infarction  alwaj'S  results. 
That  a  part  is  able  to  retain  its  vitality  after  the  occlusion  of  a  large 
artery  supplying  it  with  blood  is  due  to  the  development  of  the  collateral 
circulation.  After  the  ligation  of  the  femoral  artery  below  the  point 
■where  tlie  jirofunda  is  given  off,  the  leg  not  only  retains  its  vitality,  but 
in  a  short  time  it  will  be  able  to  perform  all  its  functions  as  well  as 
before.  It  must  receive  the  same  quantity  of  blood,  and  it  cannot  do 
this  unless  the  other  arteries  dilate.  No  adequate  explanation  has  been 
given  for  the  dilatation  whicli  takes  place.  It  cannot  be  explained  on 
physical  grounds,  ijecause  tying  the  artery  does  not  produce  any  increase 
of  pressure  in  the  branches  given  off'  above  the  ligature.  Tlie  dilatation 
of  the  collaterals  in  this  case  is  more  complicated.  Every  tissue  receives 
just  the  amount  of  blood  which  it  needs  for  its  nutrition  and  function, 
but  no  more.  The  varying  amount  is  provided  for  by  varying  degrees 
of  contraction  of  the  muscular  walls  of  the  arteries.  Where  a  small 
artery  has  to  supply  a  large  part  with  blood,  it  not  only  dilates  to  the 
fullest  extent,  but  the  calilire  of  the  vessel  actually  grows  larger.  The 
dilatation  is  the  result  of  the  close  relation  between  the  calibre  of  the 
arteries  and  the  needs  of  the  tissue — a  relation  probably  directly  under 
nervous  control. 


IV.  HYPERTROPHY  AND  REGENERATION. 

Ix  hypertroijhv  there  is  an  increase  in  the  size  of  an  organ  or  part 
of  the  body,  with  retention  of  the  normal  structure.  In  regeneration  a 
loss  of  substance  in  an  organ  or  part  of  the  body  is  restored  by  a  tissue 
similar  to  that  which  is  lost  or  M'hich  contains  the  same  constituents. 


216  SURGICAL  PATHOLOGY. 

A  tissue  ran  cnlargo  either  by  ;iii  increased  power  of  assimilation  or 
growth,  or  hycliniiniition  of  the  consumption  of  the  tissue.  Sucli  a  con- 
dition is  physiological  during  the  entire  period  of  growth.  When  a  part 
is  growing,  more  tissue  is  formed  than  is  used  up.  The  normal  size  of 
organs  and  the  general  conditions  of  growth  depend  upon  causes  which 
are  inherent  in  the  germ.  In  order  that  growth  may  take  place  an 
abundant  nutrition  is  necessary,  which  is  provided  in  the  intra-uterine 
life  by  the  mother  and  in  extra-uterine  life  by  alimentation.  The  growth 
of  the  individual  tissues  and  organs  is  dependent  also  on  the  activity  of 
the  blood-  and  the  lymph-circulation.  An  extremity  of  a  child  ceases 
to  grow,  or  it  may  even  diminish  in  size,  when  for  any  reason  the  blood- 
supply  is  diminished.  If  all  the  conditions  of  nutrition  are  favorable, 
and  if  there  are  no  general  disturbing  iuHuences  acting  on  the  tissues, 
such  as  abnormal  temperature,  for  instance,  the  development  and  growth 
of  every  individual  take  place  at  a  rate  corresponding  to  the  age.  The 
influence  of  the  nervous  system  for  such  growtli  as  this  is  not  absolutely 
necessary.  Examples  of  this  are  given  in  the  monstrosities  in  which 
children  are  born  without  either  brain  or  spinal  cord.  In  these  cases 
the  body  may  sometimes  show  a  develo[)ment  even  in  excess  of  the 
normal.  The  cells  apparently  from  the  beginning  have  the  {>ower  of 
excessive  reproduction — that  is,  reproduction  in  excess  of  the  material 
used  up — for  a  certain  length  of  time,  which  differs  in  different  animals. 
This  ceases  in  man  at  about  the  twenty-second  year,  and  nothing  can 
again  excite  it.  This  does  not  hold  for  certain  tissues ;  as,  for  instance, 
for  muscles,  for  glands,  and  for  the  ejiithelial  tissues  generally.  In  these 
the  power  of  forming  new  substance  does  not  cease  with  the  end  of  the 
period  of  growth.  Every  muscular  contraction  and  every  secretion  of  a 
gland  takes  place  at  the  expense  of  the  substance  of  tlie  muscle  and  the 
gland ;  and  in  order  to  supply  this  continual  loss  there  must  constantly 
be  a  new  formation  of  contractile  substance  or  of  gland-cells.  Even  in 
the  adult  there  may  be  an  increase  in  the  size  of  certain  parts  brought 
about  by  exercise  and  good  alimentation.  Arterial  congestion,  however, 
no  matter  how  excessive,  will  not  of  itself  produce  an  increased  growth. 
Apparently  the  cells  of  the  muscles  and  glands  will  only  assimilate  when 
they  are  stimulated,  and  congestion  alone  will  not  produce  contraction  in 
the  muscle  nor  increased  secretion  in  a  gland.  In  other  tissues  assimila- 
tion and  new  formation  apparently  only  depend  upon  conditions  which 
govern  the  growth  ;  that  is,  the  inherent  power  of  reproduction  and  the 
degree  of  congestion.  In  all  of  these  tissues  an  excess  of  production 
may  take  place  when  they  are  subjected  to  constant  hypersemia.  Cohn- 
heim  thinks  that  the  growth  of  these  tissues  is  due  alone  to  the  regula- 
tion of  the  blood-supply.  He  says  that  the  bones  and  epidermis  cease 
to  grow  at  the  end  of  the  growth  period,  merely  because  if  all  the  other 
organs  of  the  body  are  supplied  with  blood  in  the  proper  measure,  the 
quantity  of  blood  which  they  receive  will  not  be  sutiicient  to  excite 
growth. 

The  increase  of  size  of  organs  due  to  increased  functional  activity 
with  inci'eased  blood-supply  is  familiar  to  us  in  the  muscles  and  in 
the  glands.  When  more  ^^'ork  is  thrown  on  the  heart  in  conserjuence 
of  increased  pressure  which  has  to  be  overcome,  or  in  consequence  of 
lesions  of  the  valves,  that  portion  of  the  heart  which  is  called  upon  to  do 


HYPERTROPHY  AND  REGENERATION.  217 

an  increased  amount  of  work  beeomcs  cnlartjcd.  An  enlargement  of  the 
muscular  walls  of  tiie  bladder,  wliich  relatively  can  exceed  tliat  of  tiie 
heart,  takes  place  when,  because  of  stricture  of  the  urethra  or  enlarged 
prostate,  it  is  forced  to  do  a  greater  amount  of  work  in  expelling  its 
contents.  The  same  thing  may  be  seen  in  the  glands.  AVhen  one  kidney 
is  destroyed,  the  other  can  undergo  such  an  increase  in  size  and  weight 
that  it  will  correspond  to  both  kidneys  and  properly  perform  the  func- 
tions of  two.  In  other  glands  wliich  are  not  necessary  for  the  life  of 
the  individual,  but  only  for  the  jtreservation  of  the  species,  as  the  testicles 
in  man  and  the  ovaries  and  nianimarv  glands  in  the  female,  such  a  com- 
2:)ensatory  hypertrophy  does  not  take  place  at  all  or  only  to  a  very  limited 
degree.  Hypertrophy  only  occurs  when  in  consequence  of  the  loss  of  one 
organ  a  gi-eater  amount  of  work  is  thrown  upon  another  organ  ;  and  this 
will  not  be  the  case  for  the  testicle  or  the  ovary.  Extirpation  of  a  jiart 
of  the  thvroid  gland  will  lead  to  an  increased  size  of  the  part  which 
remains ;  not  only  that,  but  other  glandular  structures  whicli  probaljly 
have  the  same  function  will  also  undergo  an  increase  of  size  after  extir- 
pation of  a  part  of  the  thyroid  An  increase  in  the  functional  activity  of 
one  portion  of  one  lung  in  consequence  of  inactivity  in  other  portions 
will  simply  produce  a  distention  of  the  alveoli  of  the  lung  which  may  lead 
to  atro})liv  instead  of  hypertrophy.  In  general,  the  younger  the  tissue 
the  more  readily  will  compensatory  hy[)ertrt)j)hy  take  place.  In  tissues 
which  are  constantly  being  used  up  a  diminished  consumption  may  also 
produce  hypertrophy.  For  instance,  in  the  epidermis  and  the  nails 
there  is  constant  consumption  of  the  horny  layer,  and  anything  which 
interferes  with  this  constant  rubbing  off  may  lead  to  pathological  thick- 
ening. The  removal  of  pressure  from  tissues  can  also  lead  to  new  form- 
ation of  tissue.  The  inner  surface  of  tlie  skull  can  become  thickened 
when  the  growth  of  the  brain  in  childhood  is  inhibited.  Frequently- 
repeated  mechanical  and  chemical  irritation  of  the  tissue  may  lead  to 
liypertrophy.  Repeated  irritation  of  the  skin  can  lead  to  the  production 
of  callosities  and  corns.  The  continuous  inhalation  of  dust  can  lead  to 
development  of  connective  tissue  in  the  lungs,  but  this  cannot  be  consid- 
ered as  hyjiertrophy  in  the  true  sense  of  the  word.  It  is  rather  a  repro- 
duction of  tissue  to  take  the  place  of  that  which  was  lost,  and  the  new 
tissue  has  not  the  same  structure  and  function.  The  cause  of  hyper- 
trophy in  many  cases  is  entirely  unknown. 

Formerly  a  sharp  distinction  was  made  between  hypertrophy  and 
hyperplasia.  By  hypertrophv,  strictly  speaking,  we  understand  an  in- 
crease in  the  size  of  an  organ  due  to  an  increased  size  of  its  constituent 
elements,  without  any  new  formation.  In  hyperplasia  there  is  a  new 
formation  of  tissue.  These  terms  can  be  used  interchangeably,  for  in 
hypertroj)hy  there  is-always  hyj)erj)lasia.  It  cannot  be  always  assumed 
that  \\hen  an  organ  is  increased  ni  size  there  is  at  the  same  time  increased 
functional  capacity,  because  the  liyjiertmiihy  may  not  concern  all  parts 
of  tlie  organ.  When  a  gland  is  increased  in  size,  this  may  be  due  to  an 
increase  in  all  of  the  elements  of  the  gland,  or  only  the  connective  tissue 
may  be  increased  in  amount.  This  imperfect  new  formation  of  tissue 
can  reach  such  an  extent  that  hy]iertrophy  may  take  place  in  one  tissue 
of  the  gland  while  the  other  part  undergoes  atrophy.  In  such  cases  it 
is  generally  the  specific  constituents  of  the  tissue,  the  ganglion-cells,  the 


218  SURGICAL  PATHOLOGY. 

nerves,  the  gland-cells,  etc.,  that  are  atrophied,  while  the  connective  tissue 
increases  in  amount.  One  of  the  most  striking  examples  of  this  is  seen 
in  the  pseudo-hypcrtrojjhy  of  the  muscles.  Although  the  muscles  appear 
to  l)e  enormously  increased  in  size,  this  is  not  due  to  an  increase  in  the 
contractile  substance.  Hypcrtrojjhy  may  also  take  place  in  the  jicriod 
of  embryonic  development  or  during  the  period  of  extra-uterine  growth 
without  our  being  able  to  assign  any  cause  whatever  for  the  increased 
growth  of  the  tissue. 

The  power  of  regeneration  in  tissues  is  always  more  or  less  limited. 
Tlie  more  highly  develo])cd  tiie  tissue,  the  more  its  elements  are  differ- 
entiated for  particular  functions,  the  less  complete  is  the  regeneration. 
In  the  lower  animals  the  power  of  regeneration  exists  to  a  very  much 
greater  extent  than  in  man.  Whole  extremities  of  crabs  and  lobsters 
can  be  regenerated,  and  even  in  the  lower  vertelirates  the  same  power 
exists.  Tiie  yotmger  the  animal  the  greater  the  jiower  of  regeneration. 
In  man  the  power  of  regencrati<in  is  limited,  ^^"hole  pieces  of  tissue 
built  up  of  complex  elements,  such  as  a  finger  or  portion  of  the  brain 
M-liich  is  lost,  do  not  regenerate.  In  adults  the  ganglion-cells  of  tlie 
nerve-centres  have  no  power  of  regeneration.  In  the  highly-develo{)ed 
glands  the  power  of  regeneration  exists  to  some  degree,  but  is  limited. 
Single  cells  of  the  gland  when  lost  are  easily  replaced  by  multiplication 
of  surrounding  cells,  but  when  large  areas  are  lost  the  structure  of  the 
gland  is  only  imperfectly  reproduced,  and  granulation  and  cicatricial 
tissue  take  the  place  of  the  lost  substance.  The  surface  epithelium,  the 
epithelium  of  the  glandular  ducts,  the  connective  tissue,  and  the  nerve- 
fibres  have  the  power  of  regeneration  to  a  marked  degree. 

When  a  tissue  whose  elements  corresjiond  to  the  normal,  but  which 
does  not  perfectly  agree  with  the  type  of  tlie  tissue  in  Avhich  it  has  devel- 
oped, is  produced  in  a  })art,  such  a  new  formation  is  called  a  heteroplasia. 
For  instance,  a  cicatrix  in  the  liver  rejiresents  a  heteroplasia,  because, 
although  it  is  composed  of  connective  tissue  and  may  contain  tyjjical 
glandular  elements,  its  whole  structure  does  not  agree  with  the  structure 
of  the  liver,  although  tiiis  also  contains  connective  tissue  and  glandular 
elements.  The  connective-tissue  liyperplasia  which  takes  place  in  the 
course  of  inflannnation  may  also  be  regarded  as  heteroplasia.  There  is 
also  a  condition  known  as  heterochronia ;  that  is,  a  tissue  may  be  formed 
M  hich  represents  a  normal  type  at  a  certain  period  of  development,  but 
wliich  no  longer  conforms  to  the  normal  type.  Hypertrojjhy  and  regen- 
eration are  always  associated  with  an  increase  in  the  number  of  the  con- 
stituent elements.  Increase  in  size  of  an  organ  may  be  brought  about 
by  a  simple  increase  in  tlie  size  of  the  single  cells,  but  this  does  not  play 
any  jjart  in  pathology. 

Tiie  division  of  the  cells  wliich  leads  to  a  new  formation  of  tissue  is 
characterized  by  peculiar  processes  which  take  place  in  the  nucleus  and 
protoplasm.  Recent  iixvestigations  have  .shown  that  both  the  body  of 
the  cell  and  the  nucleus  possess  a  complex  structure.  In  botli  the  jiro- 
toplasm  and  in  the  nucleus  a  thread-like  structui-e  can  be  distinguished 
whicli  encloses  more  or  less  numoi'ous  granules,  some  of  which  have  a 
perfectly  definite  form.  Sometimes  these  threads  are  so  arranged  as  to 
form  a  reticulum  or  sponge-work  in  the  tissue.  In  the  nucleus  a  thread- 
like reticulum  is  formed,  and  the  points  where  the  threads  join  form  the 


HYPERTROPHY  A^W  REGENERATION.  219 

granules.  In  various  places  the  nodal  jioints  are  larger  and  more 
marked.  This  same  tibriUa  structure  is  more  condensed  around  the 
outside  of  the  nucleus  and  forms  here  a  sort  of  membrane.  In  the  cell 
itself  much  the  same  structure  can  be  recognized,  but  the  granules  and 
threads  in  the  cell  stain  differently  from  those  in  the  nucleus.  The 
division  of  the  cell  is  preceded  by  changes  both  in  the  protoplasm  and 
in  the  nucleus.  The  chromatin  of  the  nucleus  becomes  arranged  in  a 
different  manner,  and  this  change  in  the  luicleus  seems  to  be  preceded 
by  changes  in  a  peculiar  body  in  the  eell-protoi)lasm,  known  as  the 
centresome.  This  body  apparently  divides  first,  and  the  two  granules 
become  arranged  on  either  side  of  the  nucleus.  An  unstained,  spindle- 
formed  structure  extends  from  this  botii  into  the  cell  and  intc>  the 
nucleus,  and  then  the  various  changes  in  the  nucleus  take  place.  Divis- 
ion of  the  cell  so  brought  about  is  known  as  the  karyomitotic,  or  the 
indirect  cell-division.  It  was  at  first  supposed  that  this  was  the  only 
way  in  which  cell-division  took  jilace,  but  there  is  also  a  direct  division 
of  the  nucleus.  This  form  of  cell-division  is  seen  both  in  the  leuco- 
cytes and  in  the  lym]ihocytes. 

Tile  formation  of  new  cells  is  the  first  stage  in  regeneration.  The 
new  cells  provide  the  formative  tissue  from  which  the  typical  tissue  of 
the  part  is  developed.  In  the  regeneration  of  tissues  the  different 
embryonic  tissues  only  produce  the  same  tissue.  The  epithelial  cells 
can  under  no  circumstances  produce  cartilage  or  bone,  nor  is  a  connec- 
tive-tissue cell  able  to  produce  cither  the  surface  or  the  glandular  epi- 
tlielium.  This  law  was  formerly  not  so  clearly  known,  and  many 
authors  believed  that  the  most  different  tissues  could  be  formed  from 
connective  tissue.  In  the  formation  of  the  epithelial  tissues  the  cells 
become  united  to  one  another  by  intercellular  substance,  the  structure 
conforming  to  the  type  of  the  normal  tissue.  In  the  formation  of  con- 
nective tissue  the  most  prominent  feature  is  the  formation  of  intercellular 
sulistance  from  the  cells,  and  the  eharai'ter  of  this  intercellular  substance 
gives  the  various  connective  tissues  their  ])eculiar  properties.  In  order 
that  hypertrophy  or  regeneration  of  the  tissue  may  take  place  the  cells  must 
have  the  power  of  multiplication.  Most  of  the  cells  of  the  body  possess 
this  ])ower,  but  others  seem  to  have  apparently  lost  it.  These  are  cells 
which  in  the  course  of  development  have  undergone  a  marketl  differentia- 
tion. The  more  the  jirotoplasm  of  the  cell  departs  from  the  t3'pe  of  the 
embryonic  cell  by  differentiation  for  sjiccific  purposes,  the  more  does  it 
lose  its  power  of  regeneration.  The  horny  layers  of  the  epidermis,  the 
non-nucleated  red  blood-corpuscles,  the  ganglion-cells  of  the  brain  of  an 
adult,  all  seem  to  have  lost  their  power  of  multiplication.  The  more 
inilifferent  cells,  such  as  the  connective-tissue  cells,  those  of  the  bone- 
marrow,  of  the  spleen,  of  the  lympli-glands,  and  certain  of  the  epithelial 
cells,  have  retained  this  power  to  a  marked  degree. 

The  power  of  multiplication  is  one  inherent  in  the  cells  themselves, 
and  even  when  separated  from  their  surroundings  and  placed  in  new 
localities  they  are  still  able  to  proliferate.  On  this  power  of  groMiih 
depends  the  possibility  of  the  successful  transplantation  of  tissue ;  that 
is,  the  transference  of  a  piece  of  tissue  from  one  place  into  another  part 
of  the  body.  Pieces  of  the  periosteum  or  of  the  bone-marrow  have 
been  placed  in  various  parts  of  the  body  or  in  blood-vessels,  and  have 


220  SURGICAL  PATHOLOGY. 

there  grown  and  devclojjed  normal  tissue.  The  experiments  which  Jolin 
Hunter  made  in  transplanting  the  spurs  of  young  eocks  into  the  comlj, 
where  they  grew  more  actively  than  in  their  normal  situation,  are  well 
known.  The  tissue  most  frequently  used  for  transplantation  is  the  skin, 
and  this  method  may  be  used  to  make  up  even  large  losses  of  substance. 
The  great  power  of  reproduction  in  embryonic  tissues  has  been 
shown  by  experiments  in  the  transplantation  of  tissue.  The  cartilage 
of  an  adult  animal  either  does  not  grow  at  all  or  makes  a  very  feeble 
growth  when  transplanted  to  new  tissue.  Portions  of  embryonic  carti- 
lage so  transplanted  lead  to  an  excessive  growth.  Leopold  and  Zahn 
transplanted  pieces  of  embryonic  cartilage  into  the  anterior  chamber  of 
the  eye  and  obtained  a  considerable  new  formation  of  cartilage.  The 
transplantation  of  tissue  must  be  done  in  animals  of  the  same  species, 
because  the  blood-serinn  and  tissue-juices  of  an  animal  of  one  species 
generally  have  a  poisonous  action  on  the  cells  of  an  animal  of  another 
species.  The  transplanted  tissue  must  also  have  a  certain  amount  of 
cohesion  and  firmness,  otherwise  tiie  intercellular  substance  will  be  dis- 
solved out  and  the  tissue  destroyed.  It  is  prol^able  also  that  the  cells 
need  contact  with  the  adjoining  cells — that  they  derive  mutual  sup- 
port from  each  other  in  their  efforts  to  live  in  strange  surroundings. 
In  general,  the  growth  of  the  tissue  transplanted  is  limited.  This  is 
especially  the  case  with  pieces  of  tissue  wliich  are  implanted  deeply 
in  the  body.  Growth  only  goes  on  for  a  certain  time  ;  it  tiien  ceases, 
and  the  cells  may  disappear  by  absorption.  As  a  rule,  transplantation 
of  the  skin  is  not  only  the  most  useful,  but  is  the  most  successful.  The 
transplantation  of  skin  can  be  made  both  on  fresh  and  granulating 
wounds,  especially  tm  wounds  \\inch  are  covered  with  vascular,  actively- 
growing  granulations.  Large  thin  pieces  of  skin  whirli  have  l)een  cut  off 
Avith  a  sliarp  knife,  and  which  consist  of  only  the  epitlermis  with  the  cut 
ends  of  the  papilhe  or  only  the  upper  portion  of  the  corium,  may  be 
placed  on  fresh  granidating  wounds  and  kept  moist.  The  adhesion  of 
the  tissue  takes  place  by  means  of  the  lymj)ii  or  blood.  After  about  eight 
days  the  transplanted  tissue  becomes  firmly  united  with  the  tissue  beneath. 
Portions  of  the  tissue  may  be  kept  for  several  hours  in  normal  salt-solu- 
tion before  they  are  used  for  transplantation.  The  nutrition  of  tiie  trans- 
planted piece  of  tissue  appears  to  take  place  first  by  means  of  the  imbibi- 
tion of  nutrient  material  from  the  juices  of  the  tissue.  Later,  a  germinal 
tissue  bearing  blood-vessels  grows  up  into  the  transjilanted  tissue.  In 
some  cases  it  appears  to  be  e\'ident  that  a  direct  connection  is  formed 
between  the  blood-vessels  of  the  transplanted  tissue  and  those  of  the 
old  tissue.  It  is  hardly  possible  to  suppose  that  the  ti-ansplantation  of 
large  parts — such  as  the  entire  finger,  for  instance — would  be  successful 
were  this  not  the  case.  It  would  appear  impossible  for  an  entire  finger 
to  receive  sufficient  nutriment  l)y  means  of  imljibition  to  keep  alive. 
Before  new  blood-vessels  could  grow  from  the  Ixise  of  the  finger  into 
the  severed  part  necrosis  would  certainly  take  place,  yet  we  Iviiow  that 
portions  of  the  finger,  and  even  entire  fingers,  may  be  cut  off  and  kept 
for  some  time,  and  then  be  successfully  replaced.  When  the  surface 
epithelium  is  transplanted  the  horny  layer  is  cast  off,  and  the  adhering 
tissue  at  first  consists  only  of  the  lower  layer  of  germinal  tissue,  upon 
which  a  new  horny  layer  is  formed. 


HYPERTROPHY  AND  REGENERATION.  221 

The  process  of  pigmentation  in  the  skin  has  been  stndied  by  means 
of  the  transplantation  of  epithelium.  It  has  been  found  that  when  the 
skin  of  a  white  man  is  transplanted  on  a  negro  the  transplanted  skin 
soon  becomes  pigmented,  and  the  pigmented  skin  of  the  negro  loses  its 
pigment  when  transplanted  on  a  white  man.  This  e.\})erinient  shows 
clearly  that  the  skin-jjigmcnt  is  not  formed  in  the  epithelium,  but  is 
derived  fr<;>m  cells  in  the  tissue  lieneath,  which  have  the  physiological 
power  of  forming  pigment. 

The  question  as  to  the  cause  of  pathological  new  growth  of  tissue  in 
regeneration  and  the  conditions  necessary  for  it  to  take  place  is  quite 
obscure.  One  of  the  theories  with  regard  to  this,  and  «hicli  appears  to 
be  very  plausiljle,  is  that  the  cells  of  the  tissue  have  an  inherent  jwwer 
of  growth  wiiich  is  held  in  check  by  their  relations  to  the  surrounding 
tissues.  When  this  relation  is  altered  in  any  way,  as  when  a  loss  of 
substance  takes  place,  the  cells  in  the  vicinity,  having  the  inhibitory 
influence  of  the  surrounding  tissues  removed,  proliferate  actively.  Other 
observers  believe  that  the  cells  have  a  certain  irritability,  a  power  of 
action  which  may  take  the  form  of  growth,  and  under  the  influence  of 
certain  conditions  of  irritation  they  may  be  excited  to  growth. 

Among  the  influences  which  increase  the  capacity  of  proliferation  of 
the  cells,  and  which  lead  to  a  new  formation  of  cells,  increased  nutri- 
tion brought  about  by  hypcrremia  has  an  important  place.  It  is  certain 
that  this  congestive  hypenemia  makes  possible  an  increase  in  the  nutri- 
tion of  the  cells.  It  is  prol)aljly  necessary  for  cell-proliferation,  but  it 
is  not  probable  that  this  ah)ne  leads  to  proliferation.  The  cells  are  not 
nourished,  Ijut  they  nourish  themselves.  In  general,  it  is  probable  that 
proliferation  of  the  tissue  in  regeneration  should  be  regarded  as  a  second- 
ary process  which  in  most  cases  depends  upon  a  removal  of  the  restric- 
tions of  growth.  In  various  attempts  which  have  been  made  to  excite 
growth  by  chemical  and  mechanical  irritation  a  lesion  of  the  tissue,  a 
trauma  of  some  sort,  is  always  produced.  It  may  take  the  form  of  a 
direct  loss  of  substance  or  of  necrosis.  The  regenerative  changes  whi(^li 
take  place  in  the  epithelium  are  relatively  simple.  Division  of  cells 
takes  ])lace  by  means  of  karyokinesis,  and  may  be  easily  studied.  In 
epithelium  composed  of  several  layers  cell-division  appears  to  take 
place  only  in  the  cells  of  the  deepest  layers  near  the  lilood-vessels. 
These  cells  are  always  younger  than  the  others,  and  their  protoplasm 
has  undergone  no  differentiation.  The  formation  of  keratin,  represent- 
ing a  differentiation  of  the  cells  of  the  skin,  only  takes  place  after  the 
cells  have  been  produced  a  certain  length  of  time  and  are  removed  a 
certain  distance  from  the  centre  of  growth. 

In  the  regeneration  of  any  tissue  the  new  formation  of  cells  does  not 
seem  to  take  jilace  from  any  part  of  the  tissue  at  random,  but  onlv  from 
certain  porticjus  of  the  tissue".  This  was  first  studied  by  Flenniiing  in 
the  lymph-gland,  and  he  found  that  in  the  gland  there  are  certain  cen- 
tres of  growth  which  he  described  as  the  "  keimcentren."  In  the  liver 
such  places  are  seen  in  the  periphery  of  the  lol)ule,  and  in  the  skin  in 
the  lower  layers  of  the  e]iithelitnn.  It  is  very  ]irobable  that  this  is  due 
to  more  favorable  conditions  of  nutrition  of  the  cells  in  these  centres 
of  growth,  but  it  may  be  that  in  these  places  certain  cells  retain  their 
embryonic  power  of  growth.     The  newly-formed  cells  frequently  have 


222  SURGICAL  PATHOLOGY. 

not  the  same  morphologicuil  and  functional  character  as  the  old,  and  may 
approach  the  embryonic  type.  In  tlic  new  formation  of  epithelium  in 
the  lungs  which  takes  place  in  chronic  inflammation  accompanied  with 
extensive  loss  of  epithelium  lining  tlic  alveoli,  the  newly-formed  cells 
iu  the  alveoli  frequently  have  the  character  of  columnar  cells.  On  sur- 
faces which  are  lined  with  ciliated  epithelium  the  newly-formed  cells  do 
not  acquire  cilia  for  some  time,  and  in  the  place  of  ciliated  epithelium 
pavement  epithelium  may  be  formed.  This  is  frequently  seen  in  the 
healing  of  ulcers  of  tlie  larynx  and  trachea.  Small  losses  of  sul^stance 
in  the  surface  cpitlielium  are  usually  (piickly  replaced  by  growth  of  tiie 
epithelium  in  the  neighborliood. 

Loss  of  substance  in  the  glandular  epithelium  is  quickly  replaced  in 
case  the  structure  of  the  gland  is  not  altered.  Thus  in  the  kidney  the 
loss  of  single  cells  in  the  epitiielial  tul)ules  after  intiannnation  accom- 
panied by  desquamation  is  cpiickly  restored  by  regeneration  jiroceeding 
from  neighboring  cells  without  any  permanent  lesion  being  produced. 
If,  however,  the  structure  of  the  tissue  is  destroyed  and  the  relation 
■with  the  surrounding  tissues  altered,  complete  regeneration  is  not  apt  to 
take  place,  and  the  site  of  the  loss  of  substance  is  occupied  by  cicatricial 
tissue.  In  glands  in  wiiich  two  sorts  of  epithelium  are  found — as  the 
liver,  for  instance,  in  which  we  find  both  liver-cells  and  bile-ducts — in 
cases  of  loss  of  substance,  regeneration  takes  place  more  readily  and 
more  extensively  from  the  bile-duets  than  from  the  liver-cells.  The 
ejiithelium  lining  the  bile-ducts  is  of  the  same  character  as  that  of  the 
liver-cells,  and  represents  a  condition  more  nearly  approaching  the 
embryonic  state.  In  some  cases  after  loss  of  substance  in  glands  a  new 
formation  of  gland-tissue  takes  j>lace  in  the  same  way  as  in  the  embryo. 
In  the  compensatory  hypertrophy  of  one  gland  which  follows  the  loss 
of  a  gland  of  similar  structure  and  function  there  may  be  both  an 
increase  in  the  size  and  function  of  the  epithelium  of  the  remaining 
gland  and  also  a  new  formation  of  tissue.  This  has  been  studied  in  the 
growth  of  one  kidney  which  follows  after  removal  of  the  other,  but  it  is 
riot  yet  fully  understood.  It  is  not  certain  whether  there  is  a  new  for- 
mation of  complex  structures  in  the  kidney,  such  as  the  glomeruli,  or 
whether  these  simply  increase  in  size  and  in  functional  capacity.  If 
new  glomeruli  are  formed,  this  could  only  take  place  by  a  general  return 
of  tlie  tissues  to  the  embryonic  condition.  New  tubules  must  be  formed, 
and  at  the  end  of  these  glomeruli  must  be  produced  in  the  same  manner 
as  in  the  embryo.  In  the  growtii  of  tlie  kidney  which  takes  place 
before  the  adult  size  of  the  organ  is  reached  there  does  not  seem  to  be 
any  new  formation  of  glomeruli,  wiiich  simply  undergo  an  increase 
of  size.  The  younger  the  kidney,  the  smaller  the  glomeruli.  In  the 
epitliclium  lining  the  intestinal  canal  extensive  processes  of  regeneration 
may  take  place."  In  the  healing  of  large  typhoid  ulcers  of  the  intestine, 
ju&"t  as  in  the  healing  of  ulcers  of  the  skin,  there  is  a  new  growth  of 
epithelium  which  extends  from  the  edges  and  covers  over  the  loss  of 
substance.  In  the  newly-formed  epithelium  the  simple  glandular  crypts 
are  produced,  but  the  more  highly  differentiated  structures,  such  as  tiie 
villi,  are  not.  The  newly-formed  glands  are  not  so  numerous  nor  do 
they  have  the  same  typical  structure  as  in  the  normal  intestine. 

Sometimes  in  the  process  of  epithelial  regeneration  the  new  forma- 


HYPERTROPHY  AND  REGENERATION.  '   223 

tion  of  tissue  may  be  far  in  excess  of  that  ueccssary  to  supply  the  defect. 
The  epithelium  in  every  part  of  the  body,  especially  the  surface  epithe- 
lium, has  an  almost  unlimited  power  of  growth.  If  there  is  a  definite 
chaut;e  in  the  character  of  the  connective  tissue  beneath  it — if  the  nor- 
mal connective  tissue,  for  instance,  is  replaced  by  a  tissue  containing 
great  numbers  of  cells  with  a  small  amount  of  loose  intercellular  sub- 
stances— the  epitlielium  grows  downward  into  such  a  tissue.  At  the 
edges  of  ulcers  of  the  skin  this  atypical  growth  of  epithelium  may  take 
place  to  such  an  extent  that  the  structure  of  a  typical  epithelial  carci- 
noma may  lie  produced.  The  growth  of  the  epithelium  only  extends 
into  the  pathological  connective  tissue,  and  the  normal  tissues  are  not 
invaded  bv  it.  In  cases  of  intestinal  suture  tlie  epithelium  of  the  crvjits 
of  Lieberkiihn  grows  downward  through  the  suture,  and  an  extensive 
growth,  resembling  an  adenoma  and  extending  even  to  the  peritoneum, 
may  take  place. 

In  all  processes  of  regeneration  new  formation  of  blood-vessels  plays 
an  imjiortant  part,  because  only  by  a  new  formation  of  blood-vessels 
can  the  excessive  nutrition  which  is  necessary  for  regeneration  be 
brought  about.  New  blood-vessels  will  be  formed  even  in  non-vascular 
parts,  as  in  the  cornea.  The  new  formation  of  blood-vessels  has  been 
sufficiently  considered  in  Inflammation. 

Tlie  diffi'rent  members  of  the  connective-tissue  group  show  a  marked 
difference  in  their  respective  powers  of  regeneration,  which  are  most 
active  in  the  periosteum,  the  Ijonc-marrow,  and  the  lymphoid  tissue. 
The  cartilage,  on  the  other  hand,  is  capable  of  only  a  slight  power  of 
regeneration.  On  the  second  day  after  fracture  of  bone  the  cells  in 
the  vicinity  of  the  fracture  enlarge  and  multiplication  begins.  In  the 
physiological  regenei'ation  of  tissue  the  newly-formed  cells  take  the 
place  of  the  old.  It  is  simply  a  growth  of  tlie  old  tissue,  without  any 
intermediate  steps  and  without  any  alterations  of  structure.  When  a 
large  amount  of  young  tissue  is  formetl  in  a  short  time,  the  character 
of  the  old  tissue  is  not  immediately  reproduced,  but  the  growing  cells 
and  the  blood-vessels  form  a  germinal  tissue  which  is  usually  known  as 
granulation  tissue.  The  extent  to  which  this  is  produced  varies  in  dif- 
ferent cases,  and  depends  upon  the  cajwcity  of  growth  of  the  tissue  on 
the  one  hand  and  the  extent  of  the  lesion  on  the  other.  After  fracture 
of  bones  an  excessive  amount  of  this  germinal  tissue  may  be  produced. 
The  growing  cells  are  larger  and  richer  in  protoplasm  than  the  cells  of 
the  old  tissue.  They  may  have  one  or  two  nuclei,  and  sometimes  cells 
with  numerous  nuclei,  the  so-called  giant-cells,  appear.  All  the  cells 
may  unite  in  the  formation  of  the  future  tissue.  Wlien  connective  tissue 
develops  from  sucli  cells  they  arc  known  as  fibroblasts  or  inoblasts. 

The  formative  cells  of  cartilage  and  bone  have  I'eceived  the  name  of 
chondroblasts  or  osteoblasts.  The  most  varying  forms  of  cells  are  seen 
in  the  forming  connective  tissue.  The  first  step  in  the  formation  of 
the  definite  tissue  is  seen  in  the  appearance  of  fine  fibrillar  bundles 
between  the  cells,  or  a  homogeneous  intercellular  substance  may  be 
formed  which  afterward  l^ecomes  differentiated  into  fibrillie.  The  for- 
mative cells  increase  in  size,  and  finally  lie  in  small  spaces  in  the  tissue. 
In  the  development  of  hyaline  cartilage  a  hyaline  ground  substance 
appears  between  the  cells,  and  the  chondroblasts  assume  a  round  form. 


224  SURGICAL  PATHOLOGY. 

As  tlie  ground  substaiicp  increases  tliese  cells  heconie  smaller,  and  finally 
lie  in  round  spaces,  tiie  wall  of  wiiicli  forms  tiie  capsule  of  the  curtilage- 
cell. 

The  formation  of  new  osseous  tissue  is  a  very  complex  process.  In 
this  a  homogeneous  or  fibrinous  substance  forms  between  the  cells,  and 
afterward  becomes  infiltrated  with  lime-salts.  The  forming  cells  become 
smaller,  and  finally  lie  in  small  irregular  cavities,  and  are  designated  as 
bi)iie-cells.  When  there  is  an  abundant  formation  of  germinal  tissue 
tiiis  direct  change  of  the  tissue  into  bone  is  limited.  Within  the  ger- 
minal tissue  an  irregular  meshwork  of  firmer  tissue  may  apjiear,  due  to 
the  formation  of  firm  homogeneous  tissue  between  the  cells.  This  is  at 
first  not  calcified,  and  is  known  us  osteoid  tissue.  Afterward  the  inter- 
cellular substance  becomes  impregnated  with  lime-salts.  The  newly- 
formed  osseous  tissue  is  very  extensive,  being  softer  and  looser  in  struct- 
ure than  the  old  bone,  and  the  gradual  conversion  of  this  newly-formed 
tissue  into  a  tissue  similar  to  that  of  bone  is  quite  a  slow  process. 
Mucous  tissue  is  formed  from  the  germinal  tissue  by  the  formation  of 
homogeneous,  gelatinous,  intercellular  substance  which  contains  mucin. 
Mucous  tissue  frecpiently  represents  a  transitory  stage  of  growing  con- 
necti\e  tissue,  and  it  may  be  afterward  converted  either  into  fat  or  into 
fibrillar  connective  tissue.  Adipose  tissue  may  develop  in  places  M'hich 
normally  contain  fat  or  it  may  form  in  any  of  the  connective  tissues. 
The  regeneration  of  the  blood  is  a  process  which  is  not  well  understood, 
in  spite  of  the  frequency  with  which  it  takes  ])lace.  The  blood  is  a 
very  complex  tissue,  containing  a  nimiber  of  elements  of  different 
origin.  The  formation  of  the  round  mononuclear  cells  of  the  blood 
takes  |)lace  in  the  lymphatic  glands,  and  these  cells  are  simply  taken 
into  the  blood  from  these  glands.  We  know  very  little  about  the  for- 
mation of  the  polynuclear  leucocytes.  This  takes  place  in  the  bone- 
marrow  and  in  the  spleen,  Ijut  the  various  steps  connected  with  it  are 
not  known.  There  are  cells  in  the  blood  which  are  regarded  as  pro- 
genitors of  the  polynuclear  leucocytes,  though  the  number  is  too  small 
for  us  to  regai'd  them  as  the  only  progenitors  of  these  cells.  The  new 
formation  of  red  corpuscles  is  better  understood.  It  is  supposed  that 
they  are  formed  in  the  bone-marrow  from  certain  cells  which  are  called 
erythroblasts,  by  conversion  of  the  protoplasm  of  the  cells  into  the  red 
corpuscle,  the  nucleus  becoming  extruded. 

New  formation"  of  muscular  tissue  takes  place  only  to  a  limited 
extent  after  loss  of  substance.  The  increase  of  size  of  the  muscles  in 
hypertrophy  is  principally  due  to  increase  in  size  of  the  muscular  fibres. 
After  injury  or  loss  of  substance  in  the  muscle  the  muscle-nuclei  become 
elongated  and  divide.  The  cells  of  the  connective  tissue  and  sarcolemma 
also  show  rapid  proliferation.  The  substance  of  the  muscle  between  the 
nuclei  becomes  broken  up  into  larger  and  smaller  masses,  so  that  the 
muscle-cells  lie  in  spaces  between  these  fragments.  The  fragments  are 
absorbed,  and  a  new  formation  of  muscular  tissue  takes  place  from  the 
newly-formed  cells.  The  process  is  quite  a  slow  one,  and  is  frequently 
not  completed  until  two  months  after  the  injury.  When  the  loss  of 
substance  is  extensive  there  is  never  sufficient  new  formation  to  com- 
pletely supply  the  defect,  and  the  gap  is  occupied  by  connective  tissue. 

Regeneration  of  the  cellular  constituents  of  the  central  nervous  system 


DEATH;  XECBOSIS ;  ATROPHY;  DEGEXEBATION.  225 

does  not  take  place  in  man,  or  in  the  mammalia  generally,  in  post-embry- 
onic life.  When  there  is  a  small  loss  of  substance  in  the  central  nervous 
system  a  formation  of  connective  tissue  takes  place ;  if  the  loss  is  large, 
a  cyst  is  formed.  New  formation  of  nerve-fibres  of  the  peripheral  ner- 
vons  system  is  frequently  seen.  It  takes  place  in  all  cases  when  nerve- 
fibres  are  cut  across  or  in  any  way  jxTrtially  destroyed.  Degeneration 
always  takes  place  in  the  iieriplieral  part  of  the  nerve-fibre  after  section 
or  iiijurv  of  any  sort.  The  central  i)art,  having  a  connection  witli  the 
nerve-cell,  preserves  its  vitality,  and  from  this  growth  takes  place. 
Regeneration  begins  in  the  central  stump  of  a  nerve  a  very  few  days 
after  section,  taking  place  by  a  growth  of  the  axis-cylinder  of  thecen- 
tral  end  of  the  nerve.  When  the  peripheral  degenerated  nerve  is  in 
contact  with  the  central  end,  the  growing  fibres  will  extend  along  the 
old  ner\e  to  its  muscular  or  sensory  distrilnition.  Tlie  presence  of  the 
old  nerve  gives  the  proper  direction  to  the  growing  fibres.  If  the  grow- 
ing axis-cylinders  do  not  reach  the  old  nerve,  they  may  extend  for  some 
distance  iii  the  connective  tissues,  but  more  usually  they  either  undergo 
atropliy  or  take  various  directions  into  the  surrounding  tissues  and  are 
finally  lost.  Regenerative  processes  may  also  take  place  in  the  central 
ends  of  the  nerves  after  amputation.  The  regenerative  gi'owth  may  be 
considerable,  and  large  masses  composed  entirely  of  a  convolution  of 
rolled-np  nerves  may  appear  on  the  cut  ends  of  the  nerves.  These  are 
called  "  amputation  "neuromas,"  and  frequently  give  rise  to  a  great  deal 
of  pain. 


V.  DEATH;  NECROSIS;  ATROPHY;  DEGENERATION. 

The  tissues  of  the  body  are  only  capable  of  existing  and  preserving 
their  function  for  a  certain  length  of  time.  Their  power  of  regenera- 
tion becomes  less  and  less  as  age  advances,  and  finally  the  regenerative 
processes  are  no  longer  able  to  keep  jiace  with  the  i-apidly-advancing 
processes  of  degeneration.  Deatli  from  old  age  may  be  attributed  to  the 
gradual  wearing  out  of  the  organs  and  the  gradual  loss  of  resistance 
which  the  diminution  of  the  powers  of  regeneration  entails  upon  them. 
Life  ceases  with  the  gradual  destruction  of  the  function  of  one  organ 
after  another.  Destruction  of  the  function  of  the  heart,  of  the  lungs, 
or  of  the  nervous  system  produces  death  in  a  very  short  time.  After 
desti-uction  of  the  function  of  the  intestinal  canal,  of  the  liver,  or  of  the 
the  kidneys  the  organism  as  a  whole  is  just  as  certainly  deprived  of  life, 
but  some  time  may  elapse  befoi'e  death  takes  place. 

In  contradistinction  to  this  general  death  of  the  organism  the  local 
death  of  a  part,  or  of  single  cells  or  groups  of  cells,  is  called  necrosis. 
Witii  the  api)earance  of  this'  local  death  or  necrosis,  affecting  groups 
of  cells  or  an  entire  organ,  changes  of  structure  take  jilace.  These 
changes  of  structure  occur  so  gradually  that  it  is  impossible  to  deter- 
mine the  exact  moment  when  the  cells  cease  to  live,  and  frequently  in 
the  early  stage  of  necrosis  neither  the  microscopic  nor  the  macrosco])ic 
appearance  is  sufficient  to  tell  us  whether  necrosis  has  taken  place.  The 
causes  of  necrosis  of  the  tissue  are  various.  The  tissue  may  be  destroyed 
by  direct  mechanical  or  chemical  action.     A  finger  can  be  crushed  by 

Vol.  I. — 16 


2'2C)  SUJROICAL    I'ATJlOLOdY. 

external  violence;  a  portion  of  the  skin  may  he  destroyed  hv  sulphuric 
acid  ;  and  germs  may  destroy  tissue  in  which  they  develop.  The  thermic 
death-point  of  protoplasm  lies  between  54°  and  60°  C.  If  tissues  are 
exposed  to  this  degree  of  heat  ibr  a  short  time,  necrosis  is  ]iroduced. 
Lowering  the  temperature  does  not  seem  to  exert  the  same  uuliivorahle 
intlueuce.  Even  in  niaunnals  portions  of  the  body  may  be  (•om])Iet('ly 
frozen  for  a  short  time  and  afterward  be  restored  to  function.  \\'hen 
the  tissues  do  not  receive  the  proper  supply  of  blood  their  function  and 
resistance  may  be  impaired,  and  if  the  blood-supply  be  sufficiently 
reduced  necrosis  results.  This  form  of  necrosis  is  called  anremic 
necrosis.  Examples  of  it  are  given  in  the  various  infarctions  due  to 
artei'ial  occlusion. 

The  neuropathic  necrosis  is  due  to  interference  with,  or  inhil)ition  of 
the  function  of,  the  trophic  nerves.  Regeneration  of  the  tissue  and 
nutrition  generally  are  largely  imder  the  control  of  the  nervous  system. 
Regeneration  does  not  take  place  so  completely  when  the  nervous  supply 
of  a  part  is  destroyed.  Samuel  found  that  when  the  long  feathers  of  the 
wings  of  pigeons  are  pnlleil  out  they  are  only  incompletely  regenerated 
when  the  nerve  of  the  wing  has  l)een  cut.  The  supposed  trophic  influ- 
ence of  the  nerves,  however,  cannot  be  separated  from  the  action  of  the 
vasomotor  nerves  which  accompany  them.  As  examples  of  necrosis  due 
to  interference  with  the  functions  of  the  trophic  nerves  the  rapid  and 
severe  bed-sores  which  develop  in  the  course  of  certain  diseases,  espe- 
cially after  injury  of  the  spinal  cord,  are  cited. 

Any  condition  which  in  any  way  interferes  with  the  circulation  in  a 
part,  such  as  thrombosis,  embolism,  closure  of  vessels  by  continual  tonic 
contraction,  by  lesions  of  the  walls,  by  ligature,  by  pressure  from  with- 
out, inflammation,  hemorrhage,  etc.,  can  ])roduce  necrosis.  In  certain 
tissues  temporary  cessation  of  the  circidation  lasting  but  a  short  while 
may  produce  necrosis.  The  various  tissues  have  varying  powers  of  resist- 
ance to  disturbances  of  the  circulation.  In  general,  the  more  highly 
organized  the  tissue  is,  the  more  rapidly  does  it  succumb.  The  epithelial 
cells  of  the  kidney  will  undergo  necrosis  when  the  circulation  is  shut  off 
for  only  one  or  two  hours.  The  ganglion-cells  of  the  central  nervous 
system  are  also  very  sensitive.  Other  tissues  can  withstand  the  shutting 
off  of  the  circulation  for  a  very  much  longer  time.  The  skin,  the  bone, 
and  the  connective  tissues  generally  may  live  for  ten  or  twelve  hours 
after  the  circulation  has  been  cut  off'.  Cases  have  been  known  in  which 
small  portions  of  the  body,  such  as  the  fingers,  have  united  perfectly 
when  replaced  six  hours  after  removal.  If  the  circulation  in  the  tissue 
is  imperfect  or  its  nutrition  in  any  way  interfered  with,  as  in  general 
marasmus  or  hydriemia,  it  undergoes  necrosis  much  more  easily  than  a 
perfectly  normal  tissue.  Necrosis  takes  place  much  more  readily  in  old 
peojile  and  in  those  in  whom  the  action  <k"  the  heart  is  imperfect.  In  a 
part  subject  to  chronic  passive  congestion  or  oedema  a  very  slight  cause 
may  produce  necrosis.  Invalids  who  suffer  from  acute  diseases,  partic- 
ularly typhoid  fever,  may  have  extensive  necrosis  from  comparatively 
slight  pressure  on  projecting  parts. 

In  consequence  of  necrosis  of  a  tissue  a  more  or  less  extensive  inflam- 
mation is  produced  in  the  surrounding  parts.  This  is  more  intense  when 
putrefactive  processes  take  place  in  the  necrotic  tissue,  which  exerts  a 


DEATH;  NECROSIS;  ATROPHY;  DEGENERATION.  227 

positive  chemotiictic  attraction  foi"  the  white  corpuscles,  which  enter 
into  it  in  lariic  numbers.  A  zone  of  inflammation  is  set  up  which 
separates  tiie  necrotic  tissue  from  its  surroundings.  The  dead  tissue 
may  be  gradually  removed  by  absorption,  or  it  may  be  cast  off  as  a 
whole.  A  part  of  it  may  remain,  wiiich  can  afterward  undergo  calcifi- 
cation and  remain  in  the  tissues  as  a  foreign  body,  and  become  sui-- 
rounded  by  a  caj)sule  of  connective-tissue  formation,  or  a  cyst  may 
be  formed  in  place  of  tlie  necrotic  tissue.  This  most  commonly  takes 
place  in  the  brain,  and  it  is  also  often  seen  in  tumors. 

One  of  tiie  most  common  forms  of  necrosis  is  that  designated  as  coag- 
ulation-necrosis. This  is  necrosis  M'ith  coagulation  of  tlie  necrotic  cells 
and  the  fluid  surrounding  them.  Both  the  cells  and  the  cell-derivatives 
after  necrosis  has  taken  place  may  become  changed  into  peculiar  homo- 
geneous, dense  masses.  Inflammatory  exudations  on  a  suriace  also  unite 
with  tlie  necrotic  cells  of  the  surface  and  form  masses  of  fibrin  appearing 
as  a  membrane.  The  membrane  consists  partly  of  granules  and  partly 
of  filaments,  which  are  found  united  togetiier  to  form  thick  meshes  in 
the  tissue.  Large  hyaline  refractive  masses  can  also  form  in  this  wav. 
In  this  form  of  necrosis  various  changes  take  place  in  the  cells.  The 
nuclei  first  lose  the  normal  arrangement  of  the  chromatin,  and  become 
changed  into  solid  masses  which  may  stain  more  briglitly  than  the  nuclei 
of  the  normal  cell.  The  nucleus  appears  solid  and  homogeneous.  The 
nuclei  afterward  lose  their  sharp  contour,  become  irregular,  and  finally 
break  up  into  a  mass  of  brightly-stained  granules  which  may  be  recog- 
nized in  the  tissue  as  nuclear  detritus.  The  best  example  of  coagulation- 
necrosis  is  given  in  the  infarction  wiiich  takes  place  in  various  organs 
in  consequence  of  the  shutting  off  of  the  blood-supply.  The  cells  may 
retain  their  fin-m  for  some  time.  They  afterward  become  changed  into 
finely  granular,  homogeneous  masses  which  may  undergo  absorption. 
Coagulation-necrosis  takes  a  special  form  in  striated  muscular  fil)res. 
When  necrosis  of  muscular  fibres  takes  place  in  consequence  of  crushing 
or  tearing,  or  of  elevation  of  temperature  in  certain  diseases  accompanied 
by  high  fever,  tiie  contractile  myosin  becomes  stiftened,  and  frequently 
changes  into  refractive  iiomogeneous  masses  wiiich  may  entirely  fill  up 
the  sarcolemma.  This  form  of  degeneration  is  spoken  of  as  the  "waxy" 
or  Zenker's  degeneration.  This  may  take  place  in  the  individual  fibres 
of  a  muscle  or  may  involve  large  masses  of  a  muscle.  It  is  a  total  de- 
struction of  tiie  tissue,  and  is  not  capable  of  reparation.  Tiie  affected 
muscles  are  of  a  pale  grayish-red  color  somewhat  similar  to  the  flesli  of 
fisli,  and  liave  an  opaque  and  dry  appearance.  Tliis  form  of  degeneration 
is  fre(piently  found  in  the  muscles  of  tlie  abdominal  wall  in  typhoid  fever. 
Hemorrhage  usually  takes  place  in  the  affected  areas. 

Another  form  of  necrosis  is  known  as  "  caseation."  This  term  refers 
solely  to  the  appearance  of  the  necrotic  tissue,  and  is  used  to  designate  a 
form  of  necrosis  in  wiiich  tlie  tissue  changes  into  a  substance  resembling 
soft  white  cheese.  The  best  example  of  this  is  seen  in  the  necrosis  which 
takes  place  in  tuberculous  products.  This  caseous  tissue  is  more  or  less 
brittle,  and  appears  as  an  opaque  whitish  or  3'ellowish-white  mass.  Case- 
ation takes  place  when  masses  of  cells  with  little  or  no  tissue  between 
them  undergo  necrosis.  The  consistency  of  the  caseous  tissue  varies 
greatly.     Sometimes  it  is  firm  and  dry,  sometimes  comparatively  soft. 


228  SURGICAL  PATHOLOGY. 

Caseation  cannot  be  regarded  as  a  process  peculiar  to  tiihcrcidosis, 
although  it  is  seen  more  often  in  tuberculosis  than  in  any  other  condi- 
tion. It  is  also  seen  in  tumors  which  arc  rich  in  cells  and  contain 
necrotic  areas  due  to  disturbances  in  luitrition,  and  in  the  pathological 
products  of  syphilis,  but  the  caseation  whicli  apj)cars  in  the  course  of 
sy[)hilis  has  a  rather  different  character  from  that  seen  in  tuberculosis. 
The  necrotic  tissue  may  undergo  liquefaction.  It  becomes  saturated  with 
fluid,  and  iinally  melts  up,  forming  a  fluid  mass.  In  an  anisemic  necrosis 
of  the  brain  the  necrotic  tissue  breaks  uji  into  small  grnnidiii-  masses, 
which  are  partly  absorbed  and  partly  dissolved  in  the  circulating  lymph, 
and  a  cyst  filled  with  clear  fluid  takes  the  place  of  the  necrotic  tissue. 
Coagulation  does  not  take  place,  because  the  brain  is  so  poor  in  the 
elements  necessary  to  fibrin-formation.  The  chemical  products  pro- 
duced in  suppurative  inflammation  also  have  the  power  of  dissolving 
necrotic  tissue. 

A  peculiar  form  of  necrosis  is  that  known  as  fat-necrosis,  and  in 
connection  with  disease  of  the  pancreas  it  has  received  much  attention. 
Small  opaque  masses  are  found  in  the  fat  in  various  places  in  the 
abdominal  cavity.  They  vary  in  size  from  a  mici'oscopic  point  up 
to  areas  several  millimetres  in  diameter.  On  section  of  the  pancreas 
they  are  also  seen  in  the  connective-tissue  septa  running  thn)ugh  the 
gland.  Fat-necrosis  is  associated  with  various  diseases  of  the  ])ancreas, 
with  hemorrhage,  with  acute  suppuration,  and  with  other  conditions. 
It  is  held  by  some  authors  that  the  changes  in  the  fat  arc  primary,  and 
that  the  lesions  in  the  pancreas  are  due  to  necrosis  in  the  glandular 
septa.  It  is  held  by  others  that  the  lesions  in  the  pancreas  are  primary, 
and  that  the  necroses  of  the  surrounding  fat  are  due  to  the  action  of  the 
pancreatic  juice  which  escapes  into  the  suri'ounding  jiarts.  The  distri- 
bution of  the  areas  of  necrosis  gives  some  ground  for  this  assumption, 
l:)ut  it  has  not  been  confirmed  by  experiment.  The  necrotic  areas  in  the 
fat  are  intensely  resistant.  They  are  not  aflected  b}'  mineral  acids  nor 
by  caustic  alkalies.  The  peculiar  change  in  the  fat  is  due  to  a  combina- 
tion of  lime-salts  with  the  fatty  acids. 

ISInmmification,  or  dry  gangrene,  is  seen  in  the  senile  necrosis  of  the 
lower  extremities  and  the  toes,  and  in  the  necrosis  following  frost-bite. 
Senile  necrosis  is  due  to  imperfect  circulation  in  the  part,  resulting  partly 
from  general  weakness  of  the  circulation  and  partly  from  disease  of  the 
intima  of  the  artery  with  thrombosis,  or  from  embolism.  In  frost-bite 
the  necrosis  is  produced  by  the  influence  of  low  temperature  lasting  for 
a  considerable  time.  In  both  frost-bite  and  senile  gangrene  there  is 
venous  hypersemia  while  the  necrosis  is  taking  place.  The  necrotic 
tissue  is  filled  with  blood,  and  by  the  diff'usion  of  the  blood-coloring 
matter  the  necrotic  part  acquires  a  dark-red  or  black  ajjpcarance. 
Vesicles  are  formed  which  rupture.  The  entire  epidermis  of  the  part 
may  be  removed,  evaporation  goes  on  rapidly,  and  the  ])art  becomes 
changed  into  a  dry,  hard  mass  with  a  leathery  surface.  A  sharp  line  of 
demarcation  is  established  between  the  healthy  and  the  gangrenous  tissue, 
and  the  gangrenous  part  may  l)e  gradually  separated  from  the  living 
tissues  by  suppuration  and  softening.  The  inflannuatory  exudation  exerts 
a  dissolving  action  on  the  necrotic  tissue.  The  separation  takes  place 
readily  through  the  soft  parts,  and  in  the  course  of  time  may  extend 


DEATH;  NECROSIS;   ATROPHY;  DEGENERATIOX.  229 

tlii'onoli  tlie  hones.  Moist  ganorenc,  oi-  sphacelus,  is  ehuracterizecl  by 
decomposition  or  puti'efaction  in  the  necrotic  tissue.  This  takes  phice 
wlien  the  organisms  of  putrefaction  enter  into  a  ii'ano-renous  part  wiiich 
contains  a  hirge  amount  of  fluid.  The  gangrenous  part  may  have  its 
temperature  elevated,  this  being  due  both  to  the  process  of  decomposition 
and  to  a  surrounding  inflammation ;  and  this  condition  is  known  as  "  hot 
gangrene."  The  ])utrefactive  tissue  soon  begins  to  emit  a  foul  odor  and 
becomes  broken  down.  Sometimes  the  process  of  decomposition  is  accom- 
panied with  the  formation  of  gas,  which  may  iniiltrate  the  tissue.  Tiie 
various  tissues  of  the  gangrenous  part  show  ditferent  degrees  of  resistance 
to  the  pi-ocess  of  putrefaction.  The  bone  may  remain  for  some  time,  while 
the  soft  parts  are  rapidly  broken  down.  The  tendons  and  large  arteries 
are  also  relatively  resistant.  On  microscopic  examination  there  are  nu- 
merous liacteria  jiresent,  most  of  which  belong  to  the  anacrotjic  forms. 
The  blood-corpuscles  become  dissolved,  Ijroken  up,  and  converted  into 
masses  of  granular  pigment.  The  fat-cells  are  broken  down,  and  the  fat 
appears  in  the  form  of  small  drops  in  the  tissue.  There  are  various 
crystalline  products  of  this  decomposition.  We  may  find  crystals  of  the 
fiittv  acids  in  the  form  of  long  needles,  the  needle-shaped  crystals  of 
tvrosin,  the  globular  masses  of  leucine,  and  the  coffin-shaped  crystals  of 
triple  phosphates. 

Hypoplasia  is  the  condition  in  which  portions  of  the  body,  or  single 
organs  or  parts  of  organs,  have  an  imperfect  form  of  development  in 
consequence  of  inhibition  of  growth.  This  may  be  due  to  intrinsic  causes 
in  the  organs  themselves  resulting  from  imperfection  in  the  germ,  or 
it  mav  ])e  due  to  the  influence  of  external  causes.  When  organs  or 
parts  of  organs  are  entirely  al)sent,  the  condition  is  known  as  aplasia  or 
agenesis.  Examples  of  hypo[)lasia  are  seen  in  imperfect  growth  of  the 
bones  and  in  imperfect  development  of  the  heart  or  large  vessels  or 
of  the  genitalia  or  the  central  nervous  system.  The  normal  gradual 
development  of  a  part  may  be  interfered  with  and  a  foetal  conditi(jn  of 
the  organ  result.  The  hy])oplasia  may  affiect  organs  which  are  necessary 
for  life,  or  organs  which  serve  some  purpose  not  essentially  connected 
with  the  preservation  of  the  life  of  the  individual.  For  instance,  the 
genitals  may  remain  in  the  fetal  condition  or  in  that  of  early  childhood. 
Hypoplasia  may  produce  disturl)anees  of  function  only,  or  it  may  be 
incompatii)le  with  life. 

The  condition  of  atrophy  is  usually  separated  from  that  of  liyjxt- 
plasia.  Atropiiy  is  a  diminution  in  the  amount  of  tissue,  which  takes 
place  in  an  organ  or  part  which  has  been  noi'mally  developed.  It  may 
be  due  to  an  imperfect  power  of  regeneration  which  cannot  keep  pace 
with  the  constant  waste.  Old  age  furnishes  an  example  of  this.  There 
may  be  atrophy  either  of  the  entire  liody  or  of  any  of  the  individual  or- 
gans or  tissues  of  the  body.  An  individual  may  die  from  old  age  without 
any  preceding  disease  as  soon  as  the  atropiiy  of  important  organs  readies  a 
condition  which  is  incompatible  witli  the  proper  performance  of  function. 
There  is  a  physiological  atrophy  of  certain  organs  which  may  take  place 
in  an  early  period  of  life.  Certain  organs  which  were  necessary  for  life 
of  the  embryo  undergo  atrojihy  before  birth.  The  sexual  glands  of  the 
female  may  become  atrophied  and  incapable  of  function  long  before  tiie 
period  of  general  senile  atrophy  is  reached.    The  thymus  gland  atrophies 


230  SURGICAL  PATHOLOGY. 

before  the  completion  of  the  period  of  growth.  Anatomically,  atroi)liy 
is  usiiuilly  characterized  bv  diminution  in  size  of  an  organ.  Microscopi- 
cally, it  is  seen  in  the  diminution  in  size,  and  finally  the  complete  disap- 
pearance, of  the  specific  elements  of  an  organ.  Atropiiy  may  ])n)(hicc 
ditferent  appearances  in  dit^'ercnt  organs.  In  large  organs  rich  in  specific 
elements,  as  the  liver,  the  kidney,  the  heart,  and  the  brain,  tiie  diminu- 
tion in  size  is  the  most  striking  feature.  If  the  atrophy  is  a  general  one, 
affecting  equally  all  parts  of  the  organ,  tlie  surface  may  remain  smooth. 
If  it  takes  place  only  in  certain  parts  of  the  organ,  it  gives  to  the  sur- 
face an  uneven  appearance.  Tiie  atrophied  portions  will  l)e  depressed, 
and  the  normal  portions  will  appear  correspondingly  elevated.  Tliere 
may  be  atrophy  \Nitliout  any  macroscopic  changes  in  form.  A  bone  may 
atrophy  without  any  change  in  its  external  size  or  shape,  the  atropiiy 
having  taken  place  in  the  interior  of  the  bone  by  enlargement  of  the 
medullary  canal.  The  bones  of  old  individuals  may  be  little  more  than 
shells  enclosing  a  large  medullary  cavity.  Diminution  in  the  size  of 
atrophied  organs  is  usually  duo  to  destruction  of  tiieir  specific  elements. 
The  connective  tissue  of  the  organ  may  not  take  part  in  this  atrophy  at 
all ;  in  some  cases  it  may  be  even  increased,  so  that  an  organ  in  \\iiich 
a  considerable  degree  of  atrophy  has  taken  place  may  be  of  normal  size 
or  even  lai-ger  than  normal.  Tiiis  condition  is  seen  in  the  ])scudo-hypei'- 
trophy  of  muscles.  In  the  atro])hy  of  the  kidneys  wliich  takes  place  in 
old  age  or  in  various  otlicr  conditions  the  epithelial  cells  of  the  urinary 
tubules  gradually  become  smaller  and  finally  disappear,  and  the  tubules 
collapse.  The  epithelium  of  the  glomerulus  also  becomes  destroyed,  the 
capillaries  collapse,  and  finally  the  glomerulus  is  represented  by  a  small 
hard  mass  of  connective  tissue.  Fat  often  undergoes  a  peculiar  change 
in  conscfjuence  of  atrophy.  Tiie  fat  in  the  cell  In-eaks  up  into  small 
drops  which  become  absorbed,  and  the  cells  freed  from  fat  liecome 
transformed  into  their  original  character  as  c<mnective-tissue  cells. 

Two  forms  of  atrophy,  active  and  passive,  have  been  distinguished. 
In  active  atrophy  there  is  a  diminution  in  the  capacity  of'  growth  and 
regeneration  of  the  cells,  in  consequence  of  which  they  cannot  assimilate 
the  nutritive  material  whicii  may  l)c  lirought  to  them  in  tlie  proper 
quantitv.  In  passive  atro]ihy  the  cells  are  capable  of  growth  and 
regeneration,  but  there  is  a  diminution  in  the  amount  of  nutritive  mate- 
rial which  is  brought  to  them.  Both  of  these  sorts  of  atrophy  are  fre- 
quently combined.  Atrophy  may  be  divided  into  senile  atrophy,  atro- 
j)iiy  in  consequence  of  imperfect  nutrition,  atrophy  from  pressure,  atroiihy 
from  disuse,  and  neuropathic  atro])liy. 

Senile  atropli}'  ma}'  take  place  in  all  or  any  of  the  organs  and  tissues, 
but  it  is  frequently  more  develoj)ed  in  some  organs  than  in  others. 
Organs  such  as  the  kidneys,  the  liver,  the  brain,  and  the  heart  can 
undergo  very  important  diminution  in  size.  Senile  atrophy  is  also  .seen 
in  the  skin  of  old  people,  and  this  is  one  of  the  most  common  atrophic 
conditions  produced  liy  old  age.  The  skin  loses  its  firmness  and  elas- 
ticity and  l)ecomes  thin  and  jiarchnieiit-like. 

Atropiiy  in  consequence  of  disturbed  nutrition  is  produced  by  imper- 
fect assimilation.  It  may  affect  the  entire  organism  or  lie  more  marked 
in  certain  tissues  than  in  others.  For  instance,  the  fat  of  the  body,  tiie 
muscles,  and  the  large  abdominal  glands  show  relatively  a  greater  degree 


DEATH;  NECROSIS;  ATROPHY;  DEGENERATION.  231 

of  atropliy  than  the  other  tissues.  Local  atrophy  may  result  from  local 
interference  with  the  circulation.  An  entire  organ  may  undergo  atrophy 
in  consequence  of  diminution  in  calibre  of  its  main  artery  brought  about 
by  disease,  or  only  small  branches  of  the  artery  may  be  affected,  pro- 
ducing atrophy  of  circumscribed  portions  of  the  organ.  Atrophy  may 
be  the  result  of  pressure,  even  of  comj)arativcly  slight  degree,  when  it 
is  constantly  exerted.  It  is  due  partly  to  direct  injury  of  the  cells  of 
the  tissue  in  consequence  of  the  pressure,  and  partly  to  interference  with 
the  blood-sujiply.  The  most  typical  example  of  this  is  seen  in  the  broad 
band  across  the  lower  portion  of  the  liver  in  women,  corresponding  to 
the  line  of  the  waist,  and  which  is  the  result  of  the  pressure  of  corsets. 
Himetinies  this  is  so  marked  that  there  may  be  almost  a  complete  sepa- 
ration of  the  lower  portion  of  the  right  lobe  of  the  liver  from  the  rest. 
The  atrophied  part  of  the  liver  is  marked  by  a  thickening  and  roughen- 
ing of  the  surface  due  to  increase  in  the  connective  tissue.  The  firmest 
tissue  may  give  way  before  a  constant  pressure.  For  instance,  the  pres- 
sure by  an  aneurism  on  bone,  as  in  aneurism  of  the  aorta  jwessing  ujion 
the  sternum  or  uj)on  the  vcrtelnw,  may  produce  complete  atro})hy  and 
destruction  of  the  lione. 

Atrophy  from  disuse  is  seen  in  all  tissues  whose  ordinary  functions 
are  suspended.  It  is  more  marked  in  the  muscles,  glands,  and  bones 
than  in  any  other  jiarts.  The  atropliy  is  essentially  an  active  one.  ^\  ith 
the  diminution  in  function  the  capacity  of  tlie  tissue  for  assimilation  also 
diminishes.  There  is  also  diminution  in  the  activity  of  the  circulation 
in  organs  \\itli  imperfect  function,  and  the  atrophy  may  be  in  part  due 
to  this.  When  the  disuse  appears  during  the  period  of  development, 
and  when  the  part  in  consequence  is  imjjerfectly  developed,  the  con- 
dition may  be  regarded  as  one  of  hypoplasia.  No  sharp  line  can  be 
drawn  between  atrophy  and  hypoplasia,  since  the  hypoplasia  of  tissue 
may  be  associated  with  destruction  of  tissues  which  have  already  been 
formed.  One  of  the  best  examples  of  atrophy  from  disuse  is  seen  in  the 
diminution  in  size  of  paralyzed  parts. 

Neuroj)athic  atniphy  is  the  result  of  pathological  conditions  of  the 
nervous  system.  The  best  examples  of  neurojiathic  atrophy  are  seen  in 
the  atrophy  of  the  corresponding  nerves  and  muscles  which  follows 
atrophy  of  the  anterior  horn  or  anterior  nerN'e-regions  of  the  spinal 
cord.  After  injury  of  peripheral  nerves  the  skin  corresponding  to  their 
distriliution  may  undergo  atrophy  and  become  thin  and  shiny.  Affec- 
tions of  one  side  of  the  brain  in  fcctal  life  and  in  childhood  may  ]n'oduce 
atrophy  of  the  corresponding  portions  of  the  face  and  body.  In  this 
condition  the  jtrocess  is  not  usually  one  of  sim])le  atrophy  without  any 
preceding  change,  but  is  preceded  by  various  forms  of  degeneration, 
of  which  the  atropjiy  represents  the  last  stage.  It  is  due  to  interference 
with  the  vasomotor  system  "by  which  every  part  of  the  body  exactly 
regulates  its  nutrition.  Disuse  of  the  parts  and  the  greater  suscejitibility 
to  trauma  may  also  play  an  important  part.  Even  for  this  form  of 
atropliy  it  is  not  necessary  to  assume  the  existence  of  special  trophic 
nerves. 

Degeneration  of  Cells. — One  of  the  forms  of  degeneration  of  cells 
is  known  as  cloudy  swelling,  or  parenchymatous  or  granular  degeneration. 
The  term  M'as  first  used  bv  Virchow,  who  regarded  cloudv  swelling  as 


232  SURGICAL  PATHOLOGY. 

ail  inei'ease  in  the  size  of  the  cells  pnidueed  liy  iiicrensed  nutrition,  or 
as  hypertrophy  with  a  tcndenev  to  (leii;eneration,  hut  the  ])roet'Ss  is 
now  regarded  as  degeneration.  In  cloudy  swelling  there  is  an  increase 
in  the  size  of  the  (!ells  due  to  the  accumulation  of  fine  granules  in 
the  protoplasm.  These  granules  are  sohible  in  acetic  acid  and  insoluble 
in  caustic  potash  and  ether.  In  consequence  of  the  presence  of  the 
granules  in  the  cells  the  nucleus  is  obscured,  and  it  only  becomes 
visible  after  the  granules  are  cleared  up  by  the  addition  of  acetic 
acid.  The  process  may  be  recovered  from  and  the  cells  return  to 
their  normal  state,  or  they  may  be  converted  into  masses  of  granular 
material,  and  then  break  down  and  disappear.  Fatty  degeneration  of 
the  cells  is  frequently  comljined  with  cloudy  swelling.  It  is  best  seen 
in  the  parenchymatous  organs,  such  as  the  liver,  the  kidneys,  and  lieart. 
It  aj)pears  in  most  of  the  acute  infectious  diseases,  cs])eciallv  in  those 
which  are  accompanied  with  high  fever.  The  aifected  organs  have  a 
cloudy,  dull,  grayish  appearance.  In  the  highest  degree  of  the  affection 
they  look  as  though  they  had  been  boiled.  The  consistency  is  doughy 
and  the  minor  details  of  structure  are  oljscure.  C'loudv  swelling  is  fre- 
(juently  combined  with  a  dr()])sical  degeneration  due  to  a  swelling  of 
the  cells  from  the  absor])ti()n  of  Huid.  From  the  absor])tion  of  the  fluid 
the  interior  of  the  cell  apjtears  clear  and  the  granules  of  protoplasm  are 
separated  from  one  another  and  are  sometimes  pressed  to  the  periphery 
of  the  cell.  Such  changes  of  the  cells  are  found  in  ccdematous  tissue,  in 
inflannnatory  foci,  and  in  tumors. 

Cloudy  swelling  frequently  ])asscs  into  fatty  degeneration.  In  this 
fat-drops  are  formed  in  the  cells,  which  tinally  break  up  into  masses  of 
fatty  detritus.  Certain  tissues  of  the  body  normally  contain  a  varying 
amount  of  fat.  These  tissues  rejiresent  a  storehouse  for  fat,  which  is 
cither  introduced  from  without  or  forms  in  the  organism  and  is  dcj)osited 
in  these  places.  An  inci'ease  of  this  fat  is  not  regarded  as  fatty  degen- 
eration, but  as  lipomatosis  or  obesity.  Up  to  a  certain  degree  it  can  be 
regarded  as  physiological.  When  it  becomes  excessive  it  represents  a 
jjathological  condition.  The  deposit  of  fat  takes  place  in  the  cells  in  the 
form  of  small  drops,  which  gradually  fuse  together  to  form  large  globules, 
and  finally  a  single  large  glol)ule  of  fat  may  fill  uj)  the  entire  ceil.  The 
distinction  which  is  made  between  lijiomatosis  and  fatty  degeneration  is 
that  in  fatty  degeneration  the  fat  results  from  a  destruction  of  the  jn-oto- 
])lasm  of  the  cells  by  its  conversion  into  fat.  In  the  jiroccss  of  nutrition 
fat  is  probably  formed  by  the  destruction  of  albumin,  Init  in  fatty  degen- 
eration it  is  the  albumin  of  the  cell,  and  not  the  albumin  of  nutrition, 
which  is  broken  up.  Fatty  degeneration  especially  takes  place  under 
conditions  in  which  there  is  at  the  same  time  a  tendency  for  the  albumin 
of  the  cells  to  break  down  and  a  diminution  of  oxidation.  It  is  fre- 
quently found  in  advanced  phthisis,  in  which  the  oxidation  in  the  tissue 
is  greatly  reduced  on  account  of  the  destruction  of  lung-tissue.  It  is 
found  in  the  varying  forms  of  ansemia — both  in  the  antemia  caused  by 
direct  loss  of  blood  by  hemorrhage  and  in  other  conditions  in  which  the 
red  blo(.)d-corpuscles  are  destroyed,  causing  a  diminution  in  the  amount 
of  oxygen  conveyed  to  the  tissues.  In  the  fiitty  degenerated  cells  there 
are  larger  and  smaller  drops  of  fat,  which  are  colorless,  dark,  and  re- 
fractive.    When  these  drops  are  very  small  it  is  difficult  to  distinguish 


DEATH;  NECROSIS;  ATROPHY;  DEGENERATION.  233 

thcni  from  the  granules  in  the  protoplasm  seen  in  cloudy  swelling',  hut 
on  the  addition  of  acetic  acid  the  granules  are  cleared  U])  and  the  fat 
can  be  distinguished.  The  number  and  size  of  tlu'  fat-drops  in  tiie  cells 
vary,  but  in  general  the  drops  are  very  nuieh  smaller  than  we  lind  them 
in  the  accumulation  of  fat.  In  some  instances  the  fat  accunudates  iu 
certain  parts  of  the  cell  only.  In  fatty  degeneration  of  the  kidney  the 
fat  is  formed  in  the  periphery  of  the  cells  close  to  their  insertion.  The 
degeneration  may  not  affect  all  of  an  organ,  but  only  certain  small  areas, 
and  these  areas  by  their  opacity  and  whiteness  form  a  marked  contrast 
to  the  surrounding  tissue.  This  is  fre((ucntly  seen  in  the  heart  and  in 
the  kidney.  In  the  heart  the  altei'uation  of  the  fatty  areas  with  the  more 
normal  tissues  gives  to  the  organ  a  spotted  appearance  which  has  been 
compared  to  that  of  a  leopard  skin  or  of  a  faded  leaf.  Fatty  degenera- 
tion may  take  place  in  tiie  voluntary  muscles  in  antemia  and  in  other 
cachectic  conditions,  but  it  is  more  often  seen  in  cases  of  disuse.  Muscles 
which  have  been  for  a  long  time  paralyzed  undergo  various  degrees  of 
fatty  degeneration — a  fact  which  points  clearly  to  the  etfects  of  dimin- 
ished oxidation. 

In  certain  conditions  glycogen  may  accumulate  in  the  cells  in  the 
form  of  roiuid  globules.  It  can  be  recognized  by  hardening  the  tissues 
in  absolute  alcohol  and  staining  with  iodine,  which  gives  to  the  glyco- 
gen a  brownish-red  color.  Glycogen  is  normally  found  in  the  liver,  in 
voluntary  muscles,  in  the  myocardium,  in  the  colorless  blood-corpuscles, 
in  blood-serum,  in  cartilage-cells,  and  in  almost  all  embryonic  tissues. 
In  diabetes  the  epithelium  of  the  kidney,  especially  the  epithelium  of  the 
tul)ules  of  Henle,  may  contain  glycogen.  It  may  be  present  in  various 
forms  of  tumors,  especially  in  the  epithelial  cells  of  carcinoma,  and  is 
more  generally  present  in  carcinoma  of  the  testicle  than  in  carcinoma 
elsewhere. 

In  mucoid  or  colloid  degeneration  there  is  a  formation  of  material 
called  mucus  in  the  cells  and  in  the  tissues.  The  physiological  type 
of  this  formation  of  mucus  is  seen  iu  mucous  membranes  and  glands, 
also  in  tlie  tissue  of  tiie  umbilical  cord,  in  the  various  bursie,  and  in 
synovial  membranes.  In  nuicous  mcmliranes  the  nnicus  is  formed  in  the 
so-called  goblet-cells.  These  are  large  swollen  cells  which  have  the 
appearance  of  a  goblet,  with  a  mass  of  mucus  projecting  from  them. 
Apparently,  this  power  of  forming  mucus  exists  in  only  certain  of  the 
ej)ithelial  cells.  It  may  be  increased  under  jiathological  conditions,  as  in 
catarrhal  inflannuatiou  of  tiie  mucous  membranes,  in  which  there  is  an 
increased  formation  of  clear  mucus  both  in  the  surface  e])itlielial  cells  and 
in  the  cells  of  tiie  glands.  Pus-corpuscles  can  undergo  mucoid  degenera- 
tion and  mucin  be  formed  in  them.  In  certain  tumors,  as  in  the  niulti- 
locular  cysts  of  the.  ovary,  there  is  an  enormous  formation  of  mucin. 
Witii  regard  to  the  formation  of  mucin  in  connective  tissue,  Virchow 
believes  that  it  is  formed  by  a  secretion  of  the  cells  and  is  analogous  to 
tiie  formation  of  fat.  Koester  believes  that  in  the  mucoid  degeneration 
of  the  connective  tissue  there  is  no  new  formation  of  mucin.  The  apjiar- 
ently  mucoid  tissue  is  really  cedematous  comiective  tissue,  and  the  mucin 
already  present  in  the  tissues  is  swollen  up  by  the  imbibition  of  fluid. 
The  term  "  mucoid  degeneration  "  is  one  which  is  rather  loosely  used, 
and  it  is  probable  that  various  forms  of  degeneration  of  connective  tissue 


234  SURGICM.   PATHOLOGY. 

are  ineliuled  under  tliis  general  liead.  Colloid  degeneration  is  elosely 
related  to  the  mucoid.  Its  proiluet  appears  to  be  derived  irom  the 
metamorphosis  of  albumin,  although  we  know  nothing  definitely  of  the 
cheniiral  proeesses  of  its  formation.  It  is  formed  from  the  cells,  and 
physiologically  it  is  always  present  in  the  tiiyroid  gland,  giving  to  a 
section  of  this  gland  a  gelatinous  appearance.  It  apjjcars  first  in  the; 
epithelial  cells  of  the  gland  in  tlie  form  of  small  globules.  The  entire 
cell  may  undergo  this  transformation,  or  the  single  globules  may  be 
ejected  from  the  cells  and  unite  to  form  a  large  colloid  mass  in  the  centre 
of  the  alveolus. 

A  form  of  degeneration  known  as  hyaline  was  first  described  by 
Recklinghausen.  Its  name  indicates  its  most  characteristic  feature. 
It  is  a  perfectly  homogeneous  material  which  has  rather  indefinite  stain- 
ing reactions.  It  stains  with  eosiu,  with  carmine,  with  picrocarmine, 
and  with  certain  of  the  acid  anilines.  It  has  the  same  reaction  to 
alcohol  and  various  other-  agents  as  has  the  amyloid  material,  but  it  has 
not  the  characteristic  stain  with  iodine  which  the  latter  has.  It  is  very 
probable  that  the  hyaline  material  embraces  a  number  of  different  jtrod- 
ucts.  It  is  found  in  certain  epithelial  tissues,  where  it  is  closely  related 
to  the  colloid  material,  if  not  identical  with  this.  In  certain  forms 
of  nephritis  a  homogeneous,  firm  material  accumulates  in  the  urinary 
tubules  and  is  passed  from  the  kidneys,  appearing  in  the  urine  as  hya- 
line casts.  This  material  has  ap])ar('ntly  been  formed  by  a  degeneration 
of  the  protoplasm  of  the  cells,  and  a])])ears  first  within  the  cells  in  tlie 
fi)rni  of  small  homogeneous  drops.  There  may  be  a  similar  process  in 
the  lungs.  In  certain  forms  of  pneumonia  in  cattle  the  alveoli  may 
become  filled  with  firm,  transparent,  homogeneous  masses.  Large  epi- 
thelial cells  containing  in  their  interior  homogeneous  globules  may  be 
found  enclosed  in  the  hyaline  masses,  «hich  probably  are  derived  from 
coalescence  of  hyaline  glol)ules  formed  in  the  epithelial  cells.  The 
material  described  as  hyaline  in  some  cases  seems  to  be  identical  with 
or  closely  related  to  fibrin.  It  may  appear  in  the  form  of  homogeneous 
masses  which  entii'ely  occlude  small  blood-vessels.  This  is  fretpiently 
seen  in  the  blood-vessels  of  the  lungs  in  various  infectious  diseases,  espe- 
cially in  those  due  to  infection  with  streptococci.  It  is  also  seen  in  the 
l)loo"d-yessels  of  the  kidney,  where  it  occludes  the  capillary  vessels  of 
the  glomeruli.  This  fi>rm  of  hyaline  material  stains  in  the  same  way  as 
fibrin,  and  it  is  probable  that  it  is  identical  Avith  it.  The  newly-formed 
connective  tissue  in  chronic  inflanmiations  may  be  converted  into  a 
homogeneous,  firm  mass  in  which  no  cells  are  found.  This  is  also  spoken 
of  as  hyaline,  but  it  must  be  regarded  as  entirely  different  from  the  other 
forms  of  hyaline.  It  is  probable  that  we  shall  know  little  of  these  forms 
of  degeneration  until  the  chemistry  of  the  process  shall  be  in  some  way 
discovered. 

Amyloid  Degeneration. 

Under  certain  conditions  a  peculiar  albuminous  substance,  called 
amyloid,  is  deposited  in  the  tissues.  This  deposition  may  take  place  in 
almost  all  the  organs  of  the  Ijody,  but  a]i]iears  most  often,  in  the  order 
given,  in  the  spleen,  the  liver,  the  ki<lneys,  the  intestine,  the  stomach,  the 
adrenal  glands,  the  pauci-eas,  and  the  lymph-glands.     It  is  more  rarely 


DEATH;  NECROSIS;  ATROPHY ;  DEGENERATION.  235 

seen  in  the  adipose  tissue,  the  thyroid,  the  aorta,  the  heart,  the  muscles, 
the  ovaries,  and  the  uterus.  It  may  taive  place  in  organs  which  are  the 
seat  of  some  other  disease  or  in  those  wliieh  were  previously  sound. 
The  amyloid  material  is  generally  found  along  tlie  small  l)lood-vessels, 
especially  in  the  walls  of  the  small  arteries.  At  first  sight  it  appears  as 
though  the  entire  wall  of  the  artery  were  converted  into  amyloid,  but 
closer  examination  Mill  show  that  the  amyloid  material  is  infiltrated 
between  the  muscle-cells.  Though  spoken  of  as  a  degeneration,  it 
rcallv  is  not  produced  by  a  metamorphosis  of  the  tissue,  but  is  an  infil- 
tration which  is  deposited  between  tlie  cells  of  tlie  tissue  and  gradually 
produces  atrophy  in  tlicni.  It  is  frequently  combined  witli  other  forms  of 
degeneration,  especially  the  fatty.  Even  though  an  organ  be  sound  when 
the  dei)0sit  of  amyloid  first  takes  place,  this  deposit,  from  its  position, 
situated  as  it  is  about  the  blood-v^essels,  will  lead  to  such  disturbances 
of  tlie  circulation  and  nutrition  of  the  organ  that  other  fi)rnis  of  degen- 
eration will  occur.  If  a  section  of  sucii  an  organ,  eitJier  fresh  or  after 
hardening  in  alcohol,  be  treated  witli  an  aqueous  solution  of  iodine,  the 
amyloid  material  becomes  a  reddish-brown  mahogany  color,  contrasting 
sharply  with  the  normal  tissue,  ^vhich  has  a  slight  yellowish  tint  given  it 
by  the  iodine.  If  amyloid  material  so  stained  be  treated  with  a  dilute 
solution  of  sulphuric  acid  or  with  chloride  of  zinc,  the  brown  color  some- 
times l)cct)mes  more  intensified  or  it  may  take  a  slight  violet  tone.  A 
more  direct  reaction  is  given  by  any  of  the  blue  aniline  colors,  especially 
gentian-violet.  Fresh  sections  of  the  affected  tissue  may  be  placed  in 
the  coloring  agent  and  afterward  washed  out  in  very  dilute  acetic  acid. 
The  amyloid  substance  acquires  a  brilliant  red  color,  and  contrasts 
sharply  with  the  normal  tissue,  which  has  the  ordinary  blue  stain.  The 
situation  of  the  amyloid  in  the  walls  of  tiie  arteries  would  seem  to  indi- 
cate that  it  is  firmed  either  in  the  blood  or  in  some  special  organ,  and 
afterward  deposited  in  the  walls  of  the  vessels  and  in  the  tissues.  We 
do  not  know,  however,  any  organ  in  which  such  a  formation  could  take 
place.  The  most  prevalent  view  now  held  concerning  it  is  that  it  is 
fQrmed  from  the  albumin  in  the  place  where  it  is  found.  The  cells 
seem  to  lose  their  power  of  properly  assimilating  albumin,  and  it  under- 
goes tliis  peculiar  form  of  degeneration.  The  conditions  under  which 
amyloid  infiltration  takes  place  are  well  known.  It  is  always  found  in 
cachectic  conditions  of  the  body  brought  about  by  long-continued  sup- 
puration or  by  certain  chronic  diseases.  It  is  rather  more  frequent  in 
syphilis  than  in  any  other  disease,  and  it  is  rare  that  we  find  any  exten- 
sive visceral  lesions  of  syphilis  without  finding  a  certain  amount  of 
amyloid  in  the  tissues.  It  is  especially  apt  to  occur  in  the  chronic 
afi'ections  of  bone.  The  recognition  of  amyloid  infiltration  of  tissues  is 
very  important.  The  iiutritLon  ami  general  resistance  of  the  tissues  are 
so  impaired  that  surgical  operations  and  injuries  usually  are  not  well 
borne. 

The  amyloid  material  may  also  appear  locally,  producing  localized 
infiltration  of  the  tissue  or  solid  accumulations  of  amyloid.  Large 
nodules  which  are  entirely  composed  of  amyloid  may  form  in  the  tissues. 
Such  nodules  have  been  seen  in  the  inflamed  conjunctiva,  in  syphilitic 
cicatrices  of  the  liver,  in  the  tongue,  in  the  larynx,  and  in  inflamed 
lymph-glands.     In  cicatricial  tissue,  changes  which  appear  to  indicate 


2.3f)  SURGICAL  PATHOLOGY. 

prcccdiiitr  stages  to  amyloitl  formation  may  be  seen.  Instead  of  a  per- 
fectly definite  color-reaction  with  gentian-violet,  there  may  be  only  a 
slight  reddish  or  mahogany  tint  given  to  the  tissues.  The  corpora 
aniylacea  are  composed  of  a  sul)stance  either  amyloid  itself  or  closely 
related  to  it.  These  are  small,  firm,  round  bodies  which  varv  consider- 
ably in  size,  are  formed  normally  in  the  prostate  gland,  and  have  a  con- 
centric structure  which  gives  them  a  striking  similarity  to  starch-gramdes. 
They  have  nothing  to  do  with  the  general  amyloid  disease,  and  are  formed 
in  consequence  of  local  conditions  in  the  tissues.  In  the  prostate  thev 
appear  to  be  due  to  accumulation  of  degenerated  epithelium. 

Calcification. 

Lime-salts  may  be  deposited  within  the  tissues  in  the  form  of  a  gene- 
ral infiltration  which  is  spoken  of  as  calciiication,  or  in  the  form  of 
masses  not  connected  witli  the  tissues  and  which  are  called  concrements, 
stones,  or  calculi.  C'alcitication  never  takes  place  in  perfectly  normal 
tissues,  but  the  deposit  of  the  lime-salts  is  always  preceded  bv  necrosis. 
It  is  probable  that  the  necrijtic  tissue  undergoes  certain  modifications  in 
its  chemical  reaction,  in  consequence  of  which  the  lime-salts  held  in  sus- 
pension in  the  fluids  of  the  tissue  are  deposited  in  it.  Calcification  is 
especially  apt  to  take  place  in  dense  cicatricial  connective  tissue  which  is 
poor  in  cells  and  nuclei.  It  is  also  frequently  seen  in  the  degenerated 
tissue  in  the  walls  of  the  blood-vessels,  in  tinnors,  and,  in  fact,  every- 
where where  there  is  necrotic  tissue.  The  infiltration  may  be  found 
only  in  the  intercellular  substance,  the  cells  having  disappeared,  or  in 
some  cases  it  is  found  in  the  cells  themselves,  the  intercellular  substance 
being  little  or  not  at  all  affected.  One  of  the  most  frequent  places  in 
which  the  lime-salts  are  deposited  is  in  the  walls  of  the  large  arteries 
and  in  tiie  left  side  of  the  heart.  It  would  a|)pear,  at  first  sight,  as 
though  tliere  might  be  some  connection  between  the  lime-salts  and 
arterial  blood,  but  the  truth  is  that  the  various  forms  of  degeneration  of 
the  blood-vessels  and  the  endocardium  are  more  common  in  the  left  side 
of  the  heart  and  in  the  arteries  than  in  the  right  side  of  the  heart  and 
in  the  veins.  Thrombi  may  become  calcified,  forming  vein-stones  or 
phleboliths,  and  the  necrotic  tissue  of  an  infarction  may  also  become 
completely  calcified.  In  general,  calcification  takes  place  in  the  lower 
animals,  especially  in  the  herbivora,  to  a  much  greater  extent  than  in 
man.  In  gout  there  is  a  deposit  of  the  urate  of  soda  in  the  tissues.  This 
may  take  place  in  the  kidneys,  in  the  skin,  in  the  subcutaneous  tissues, 
in  the  tendons,  the  ligaments,  the  synovial  membranes,  and  the  cartilage 
of  the  joints.  The  favorite  seat  of  the  deposit  is  in  the  metatarso-phalan- 
geal  joint  of  the  great  toe.  It  is  probable  that  the  deposit  takes  place 
principally,  if  not  exclusively,  in  tissues  which  have  undergone  necrosis. 
It  appears  in  the  form  of  long,  slender,  needle-shaped  crystals.  A  forma- 
tion of  free  concrements  or  calculi  can  take  place  in  the  various  canals 
and  cavities  of  the  body  which  are  lined  with  epithelium.  Such  concre- 
tions may  form  in  the  intestinal  canal,  in  the  ducts  of  the  large  intestinal 
glands,  in  the  gall-ldaddcr,  in  the  urinary  tract,  and  in  the  respiratory 
passages.  All  of  these  concrements  have  an  organic  basis,  and  lime-salts 
are  deposited  in  this  material.    In  the  intestinal  glands  the  calculi  consist 


DEATH;  NECROSIS;  ATROPHY;  DEGENERATION.  237 

of  a  deposit  of  lime-salts  around  thiekened  faeces  or  various  undigested 
vegetable  masses.  Tiie  most  frequent  j)laee  for  the  formation  of  con- 
crements  is  in  the  gall-l)la<l(k'r,  wiiieh  may  contain  but  one  or  may  be 
filled  up  with  large  numbers  of  them.  A\'hen  there  are  several  present 
their  surfaces  become  faceted  by  mutual  pressure. 

These  gall-stones  are  usually  composed  of  cholesterin  united  with 
various  constituents  of  the  bile.  In  rarer  cases  they  are  formed  from 
carbonate  of  lime.  xVfter  tiie  cholesterin  is  dissolved  tliere  still  remains 
a  homogeneous  substance.  Tliere  can  be  no  doubt  that  the  formation  of 
gall-stones  is  due  to  the  incrustation  of  an  organic  mucoid  substance 
with  the  constituents  of  the  bile.  Colon  bacilli  have  been  found  in  gall- 
stones. 

The  most  imjiortant  conci'ements  and  calculi  of  the  l>ody  are  those 
found  in  the  urinary  j)assages.  They  may  form  either  in  the  kidney,  in 
the  ureter,  or  in  the  i)ladder.  In  tlie  kidney  they  not  infrequently  foriii 
large  irregular  masses  which  may  till  up  the  entire  pelvis  of  the  kidne}' 
and  extend  into  the  calyces,  or  only  small  masses  may  be  formed.  Con- 
crements  appear  in  the  tissue  of  the  kidney  itself  in  the  form  of  very 
small  masses,  which  may  either  lie  in  necrotic  epithelium  or  in  the 
lumen  of  the  tubules.  In  the  so-called  uric-acid  infarction  of  the  kid- 
ney, which  is  so  common  in  children  who  die  in  the  first  week  of  life, 
there  is  sinij)ly  a  deposit  of  urinary  sediment  in  the  occluded  tubules. 
The  large  calculi  formed  in  the  urinary  l)ladder  consist  of  an  organic 
substance,  jjrobably  related  to  albumin,  in  which  various  salts  are  de- 
jiosited.  What  sort  of  material  will  lie  dejiosited  in  these  masses  depends 
upon  circumstances.  If  large  amounts  of  uric  acid  are  excreted,  as  in 
the  uric-acid  diathesis,  calculi  may  form  conijio^ed  of  this.  A\nicn  there 
is  decomposition  of  the  urine  in  the  bladder,  with  the  jiroduetion  of 
triple  phosphates,  calculi  can  be  formed  of  this  substance.  When  a  cal- 
culus has  once  been  formed  the  irritation  which  it  produces  is  favorable 
to  its  increase.  All  sorts  of  foreign  bodies  introduced  into  the  bladder 
can  serve  as  nuclei  for  the  formation  of  calculi. 

Pigmentation. 

Many  of  the  normal  tissues  of  the  body,  both  connective  tissue  and 
epithelium,  contain  a  certain  amount  of  pigment.  The  pigment  is 
almost  always  contained  in  the  cells,  and  consists  of  brown  or  dark 
amorphous  granules.  Examples  of  such  pigmentation  are  found  in 
the  iiair  and  in  the  choroid  of  the  eye.  The  nerve-cells  in  the  central 
norv(nis  system  contain  a  small  amount  of  pigment,  and  pigment  is  also 
contained  in  the  cells  of  some  of  the  glands.  The  skin  may  show  a 
general  pigmentation,  or  the  pigment  is  seen  only  at  certain  places ;  for 
instance,  in  the  axilla  and  over  the  scrotum.  During  pregnancv  the 
pigment  of  the  skin,  especially  in  brunettes,  undergoes  a  considerable 
increase.  Tiicre  maybe  a  marked  increase  in  the  jiigment  Ijrought  about 
by  certain  diseases,  as  in  Addison's  disease,  in  which  lesions  may  be  found 
in  the  suprarenal  capsules  or  in  the  semilunar  ganglia.  The  pigment  of 
the  heart  shcnvs  considerable  increase  in  certain  forms  of  atrophv  of  the 
myocardium,  especially  in  the  atrojihy  of  old  age.  Pathological  ])igmen- 
tatiou  is  also  seen  in  the  freckles  of  the  skin  and  in  the  congenital  pig- 


238  SURGICAL  PATHOLOGY. 

nicnted  moles.  Certain  tumors  belonging  to  the  sarcomas  also  show  a 
marked  degree  of  pigmentation.  The  pigment  may  be  brown  or  show 
every  degree  of  transition  up  to  perfectly  black  masses.  It  usually  lies 
in  the  cells,  and  rarely  in  the  intercellular  substance.  Wlicn  it  is  found 
in  tile  intercellular  substance,  it  is  probably  due  to  its  being  set  free  by 
rupture  and  destruction  of  cells.  The  formation  of  pigment  seems  to  be, 
in  the  main,  a  property  of  cells  belonging  to  the  connective  tissue.  In 
the  skin,  although  the  pigment  may  be  contained  in  or  between  the 
epithelial  cells,  it  appears  to  be  formed  in  large  branched  cells  in  tiie 
subcutaneous  tissue.  The  source  of  the  pigment  has  not  been  in  all  eases 
definitely  ascertained.  It  is  true  tiiat  pigment  mav  be  formed  from  the 
blootl-eoloring  matter,  but  hemorrhage  is  not  generallv  found  in  the  areas 
where  pigmentation  is  taking  place.  The  pigment  which  is  derived 
from  the  blood  under  ordinary  conditions  is  usually  brown  or  reddish- 
brown,  and  has  not  the  deep-brown  or  black  color  found  in  other  con- 
ditions. Chemical  investigation  has  shown  that  some  of  the  pigment 
contains  iron,  while  other  pigment  is  free  from  it.  The  blood-extrava- 
sation which  takes  j)lace  in  an  ordinary  bruise  undergoes  various  changes 
of  color.  When  the  extravasation  has  taken  place  in  a  transparent 
tissue — for  instance,  in  the  pleura  or  in  the  peritoneum — a  rusty-brown 
color  may  remain  for  a  long  time  afterward.  All  these  changes  in  color 
corres])ond  to  physical  and  chemical  alterations  of  the  hfemoglobin  and 
the  iron  contained  in  this.  A\'hen  hemorrhage  takes  place  in  the  tissues, 
the  red  blood-corpuscles  may  be  takt'n  up  by  the  lymphatics  in  an  un- 
changed condition,  or  the  haemoglobin  may  be  dissolved  out  of  them  and 
taken  up  by  the  circulation.  It  is  this  dissolved  blood-coloring  matter 
which  produces  the  various  changes  of  color  in  the  neighborhood  of  blood- 
extravasations.  Blood-crystals  may  bo  formed  from  the  exti-avasated 
blood,  and  they  are  frequently  found  in  the  remains  of  old  hemorrhages. 
In  cases  of  chronic  passive  congestion  there  is  usually  a  certaiii  amount 
of  diapedesis,  and  a  brownish  color  may  be  given  the  tissues  by  the 
presence  of  the  blood-pigment.  The  best  example  of  this  is  seen  in  the 
chronic  passive  congestion  of  the  lung,  the  salmon-brown  color  in  this 
being  due  to  the  presence  of  large  cells  in  the  alveoli  of  the  lung,  which 
are  filled  with  brownish-red  or  brownish-yellow'  jiigment.  In  jaundice  or 
icterus  the  pigmentation  is  due  to  the  coloring  material  of  the  bile. 
During  life  this  is  easily  recognized  in  the  skin  and  in  the  conjunctiva. 
When  the  jaundice  first  appears  the  tissues  have  a  bright-yellow  color, 
and  after  it  has  existed  for  some  time  this  changes  into  an  olive-green 
or  a  grayish-green  color.  Jaundice  is  usually  due  to  some  condition 
which  interferes  M'ith  the  passage  of  the  bile  and  leads  to  its  absorption 
into  the  lymphatics  of  the  liver,  and  from  this  into  the  blood.  Swelling 
of  the  mucous  membrane  of  the  bile-ducts,  due  to  catarrhal  inflam- 
mation, narro^ving  or  closure  of  the  bile-ducts  by  cicatrices  or  by  the 
])resence  of  gall-stones,  tumors  develojied  in  the  bile-duct,  or  the  pressure 
of  tumors  outside  of  the  ducts,  may  all  be  followed  by  jaundice.  The  com- 
mon bile-duct  is  comparatively  large  and  thin-walled.  The  pressure  of 
the  bile  within  it  is  very  low,  and  a  ^•ery  slight  ilegree  of  distentii:>n  will 
lead  to  the  retention  of  the  bile  and  its  absorption.  Accoi'ding  to  various 
authors,  there  is  a  form  of  jaundice,  the  so-called  hsematogenous  jaundice, 
which  is  produced  by  the  conversion  of  the  haemoglobin  of  the  blood  in 


TUBERCULOSIS  AND   TUBERCLE.  239 

the  blood-vessels  into  hile-coloring  matter.  The  results  of  experiments 
have  tended  to  show  that  a  pure  ha?matogenous  jaundice  does  not  exist, 
but  there  niav  be  a  destruction  of  red  blood-corpviscles  in  the  l)lood,  and 
the  lueniatoiilin  thus  set  free  is  converted  in  the  liver  into  bilirubin  and 
then  absorbed. 

The  tissues  may  also  become  pigmented  from  pigment  which  is  taken 
into  the  liody  from  without  and  absorbed  in  the  tissues.  The  pigment 
mav  enter  the  bodv  by  means  of  the  resjiiratory  or  intestinal  tract  and 
from  wounds.  In  the  operation  of  tattooing  the  skin  is  broken  and  in- 
soluble c<iloring  material  is  rubbed  into  the  wounded  surface.  A  portion 
of  this  material  remains  in  the  tissues  at  the  place,  and  a  portion  is  taken 
up  by  the  lymphatics  and  carried  to  the  adjacent  lymphatic  glands.  In 
case  the  arm  is  tattooed  the  epitrochlear  and  the  axillary  glands  always 
contain  the  same  pigment  which  is  rut)bed  into  the  skin.  The  lungs  may 
luidergo  a  marked  ])igiuentation  in  consequence  of  the  inspiration  of  dust 
and  jiarticles  of  carbon.  A  jiart  of  the  dust  remains  in  the  lungs,  and  is 
found  both  in  the  walls  of  tiie  alveoli  and  in  the  thickened  and  indurated 
tissue  whicii  results  from  the  chronic  inflanimati(3n  set  U]i  by  the  presence 
of  the  foreign  particles.  A  jiart  of  the  material  is  carried  to  the  nearest 
lymph-glands  and  produces  pigmentation  of  these. 

An  interesting  form  of  j)igmentation  is  due  to  the  introduction  of 
silver  salts  into  the  body.  When  nitrate  of  silver  has  been  used 
medicinally  for  some  time,  the  skin  acquires  a  grayish-brown  appear- 
ance and  the  organs  may  also  become  pigmented.  The  silver  is  deposited 
in  the  form  of  tine  gi'anules  in  the  tissues  of  the  organs. 

In  malaria  there  is  a  formation  of  pigment  in  the  blood.  This  condi- 
tion is  found  in  all  forms  of  malaria,  and  is  due  to  the  destruction  of  the 
red  corpuscles  by  the  malai-ial  j)arasites  which  inhabit  them.  The  pig- 
ment which  is  formed  is  derived  from  the  luemoglobin.  It  is  found  both 
in  the  red  and  white  corpuscles.  In  the  red  corpuscles  it  is  found  in  the 
parasites  which  they  enclose.  In  the  white  corpuscles  the  pigment  is 
also  derived  from  the  parasites,  the  pigment  produced  by  them  in  the 
red  corpuscles  being  taken  up  by  the  wliite  corpuscles.  In  certain 
stages  of  tiie  disease  pigmented  parasites  may  also  be  found  free  in  the 
blood.  The  pigment  is  also  deposited  in  certain  organs  of  the  body, 
notably  in  the  spleen  and  in  the  liver. 


VI.  TUBERCULOSIS  AND  TUBERCLE. 

Tuberculosis  is  an  infectious  disease  produced  by  the  tubercle 
bacillus.  It  is  characterized  J)y  the  formation  of  larger  and  smaller 
circumscribed  nodules  called  tubercles,  by  more  diffuse  formation  of 
tissue  of  the  same  character  as  that  com])osing  the  nodules,  and  by 
various  forms  of  inflammation.  The  word  "tubercle"  was  first  used 
M'ithout  any  specific  meaning  to  describe  a  small  nodule.  In  1796, 
Baillie,  the  nephew  of  John  Hunter,  gave  the  first  description  of 
tubercle  as  found  in  the  lungs.  It  was  noticed  that  these  tubercles 
were  frequently  found  associated  with  a  destructive  disease  of  the  lungs, 
and  finally  both  the  tubercles  and  the  destruction  of  lung-tissue  accom- 


240  SURGICAL  PATHOLOGY. 

panying  their  presence  were  referred  to  one  and  the  same  cause.  After- 
ward nodules  of  a  similar  character  were  found  in  the  lymph-glands,  in 
the  tissues  of  diseased  joints,  and  in  various  other  phices  in  the  lx>dy. 
It  was  ft)und  that  wherever  these  nodules  apjieared  they  were  eom])osed 
essentially  of  the  same  sort  of  tissue,  and  that  they  were  particularly 
prone  to  a  form  of  degeneration  by  which  they  became;  (;hanged  into  a 
substance  resembling  certain  sorts  of  cheese.  Tissue  of  the  same  general 
character  as  the  tubercles  was  also  found,  not  in  circumscribed  masses, 
but  rather  diffusely,  and  it  was  found  that  this  tissue  also  underwent 
caseation.  When  inflammation  accompanied  the  process  the  products  also 
became  caseous.  There  is  no  douI)t  that  althouo-h  the  form  of  dcgen- 
eration  called  caseation  is  not  a  specific  process  limited  to  the  tuberculous 
tissue,  it  so  commonly  takes  place  in  this  that  it  has  served  more  than 
any  other  morphological  factor  to  nnite  under  one  head  the  various 
manifestations  of  tiie  disease.  The  conception  of  tuberculosis  as  an 
infectious  disease  was  founded  on  the  anatomical  study  of  the  disease 
and  its  mode  of  progression  l>efore  the  discovery  of  the  sj^ecific  organ- 
ism. Even  twenty  years  before  the  discovery  of  the  bacillus  it  was 
found  that  a  disease  agreeing  in  all  essential  respects  with  the  disease  as 
found  in  man  could  be  induced  in  rabbits  by  inoculating  them  with  the 
products  of  the  disease  from  man. 

It  is  now  universally  acknowledged  that  a  bacillus  is  the  cause  of  the 
disease.  This  was  demonstrated  by  Koch  in  1881,  and  all  the  work 
which  has  since  been  done  has  served  to  confirm  the  work  of  Koch. 
The  bacillus  tuberculosis  is  one  of  the  .smallest  of  micro-organisms.  It 
is  from  one-quarter  to  one-half  the  diameter  of  a  red  blood-corpuscle  in 
length,  and  the  length  is  usually  five  or  six  times  the  breadth.  The 
bacilli  are  usually  somewhat  bent  and  the  ends  are  roiuided.  Special 
methods  of  staining  are  necessary  to  demonstrate  them.  A  great  many 
methods  have  been  given,  but  they  all  consist  in  the  use  of  fluids 
which  stain  intensely,  followed  by  decolorizing  solutions  which  remove 
the  color  from  everything  but  the  bacilli.  When  stained  the  bacilli  may 
be  of  a  homogeneous  color,  or  they  may  show  an  alternation  of  intensely 
stained  particles  and  clear  spaces.  These  clear  spaces  were  first  sup- 
posed to  represent  spores,  but  it  is  doubtful  whether  they  should  be  so 
considered.  It  is  probable  that  there  is  no  growth  of  the  organisms 
outside  of  the  body  under  ordinary  circumstances.  Special  media  and 
an  elevated  temperature  are  necessary  for  their  growth,  which  is  very 
slow,  there  being  usually  no  indication  of  it  for  several  weeks.  There 
is  a  great  difference  in  the  susceptibility  of  different  animals  to  the  dis- 
ease. Guinea-pigs  are  among  the  most  susceptible,  and  these  succumb 
in  from  six  weeks  to  three  months  after  inoculation. 

For  a  long  time  no  typical  .structure  was  regarded  as  characteristic 
of  tubercle.  Virchow  described  the  tubercle  as  a  nodule  composed 
of  small  round  cells  similar  to  those  foimd  in  granulation  tissue,  and 
derived  from  multi])lication  of  the  connective-tissue  cells,  and  called 
attention  to  the  tendency  of  the  cells  in  the  centre  of  the  nodule  to 
xmdergo  necrosis.  As  the  methods  of  histological  investigation  improved 
tubercle  was  studied  more  closely,  and  it  was  found  to  have  a  more 
or  less  typical  structure.  Langhaus  gave  a  more  detailed  description 
of  certain   large  multinucleated   cells  commonly  found  in  tubercle ;  a 


TUBERCULOSIS  AND  TUBERCLE.  241 

peculiar  reticulum  betweeu  the  cells  was  described  by  other  observers. 
AMieu  a  very  young  miliary  tubercle  is  examined  after  suitable  methods 
of  hardening,  a  reticulum  is  seen,  in  the  meshes  of  wliich  the  cells  lie. 
The  extent  to  which  the  reticulum  is  developed  depends  upon  the  age 
of  tlic  tubei'cle  and  the  character  of  the  tissue  in  which  it  develops.  It 
may  be  as  firm  and  definite  as  the  reticulum  of  a  lymphatic  gland,  and 
in  other  cases  scarcely  a  trace  of  it  may  be  seen.  Tliere  are  various  sorts 
of  cells  in  the  nodule,  the  most  prominent  of  which  from  their  number 
are  the  epithelioid  cells.  These  are  cells  somewhat  resemljling  epithelial 
cells  ;  they  have  a  pale,  finely-granular  or  homogeneous  protoplasm  and 
large  oval  vesicular  nuclei.  The  arrangement  of  these  cells  with  refer- 
ence to  the  reticulum  varies.  Sometimes  they  appear  to  lie  in  the  meshes 
of  a  more  or  less  fibrous  reticulum  ;  sometimes  tiiey  form  the  reticulum. 
The  cell-outlines  are  never  clear  and  distinct ;  the  cells  are  usually  fused 
together.  The  epithelioid  cells  are  also  found,  not  as  distinct  groujis, 
but  more  or  less  scattered  in  the  tissue.  Among  the  epithelioid  cells, 
lying  bet\\"een  them  or  in  tlie  meshes  formed  by  their  union,  are  round 
cells  similar  to  those  found  in  young  granulation  tissue.  These  cells 
vary  in  number,  and  are  most  abundant  in  the  periphery  of  the  nodule. 
The  large,  multinucleated  giant-cells  are  a  prominent  feature  of  the 
tubercle.  Sometimes  one  of  them  forms  the  centre  of  the  nodule,  and 
has  long  processes  which  communicate  with  the  reticulum  ;  or  they  may 
be  ]K'rfectly  round,  without  processes,  and  lie  in  a  space  surrounded  by 
epithelioid  cells.  In  some  cases  they  are  situated  in  the  periphery  of 
the  nodule.  The  nuclei  of  the  giant-cells  are  either  arranged  around 
the  periphery,  with  their  long  axis  perpendicular  to  the  centre,  or  they 
are  grouped  in  masses  at  eitlier  end  of  an  elongated  cell.  The  histogenesis 
of  the  tubercle  has  been  carefully  studied,  but  we  are  still  far  from  com- 
pletely understanding  it.  Baumgarten  considers  the  ej)ithelioid  cells  as 
the  most  important  cells  found,  and  that  they  are  derived  from  the  pre- 
existcnt  cells  of  the  tissue  under  the  influence  of  the  tubercle  bacilli. 
They  may  be  formed  from  the  epithelial  cells  of  glands,  fi-oni  the  con- 
nective-tissue cells,  or  from  the  cells  of  the  blood-vessels.  According  to 
Baumgarten,  the  first  step  in  the  formation  of  a  tubercle  is  the  presence 
of  tubercle  bacilli  in  the  tissue.  These  enter  into  the  fixed  cells,  no 
matter  what  the  character  of  these  may  be,  and  ])roduce  cellular  pro- 
liferation, the  newly-formed  cells  being  the  epithelioid  cells.  The  pro- 
duction of  the  giant-cells  is  a  more  obscure  process.  Weigert  thinks 
that  they  are  prothuK'd  by  the  proliferation  of  degenerated  cells,  the 
nucleus  dividing  without  separation  of  the  protoplasm.  In  some  cases 
they  appear  to  he  produced  by  fusion  of  the  epithelioid  cells,  and  they 
are  undoubtedly  sometimes  formed  in  blood-vessels,  and  may  be  traced 
in  continuity  with  vessels.  The}-  are  probably  formed  in  a  variety  of 
ways.  The  small  round  cells,  found  in  varying  numbers  in  the  tubercle, 
are  derived,  like  the  granulation-cells,  from  multiplication  of  the  con- 
nective-tissue cells  in  tlie  tissue  in  which  the  tubercle  is  formed.  Little 
is  known  of  the  formation  of  the  reticulum.  It  is  probablj- in  large  part 
composed  of  the  remains  of  the  connective-tissue  fibres  which  have  been 
pressed  apart  by  the  proliferating  cells.  It  may  be  in  part  newly  formed 
by  the  cells  of  the  tubercle,  which  for  the  most  part  are  derived  from  the 
connective  tissue  and  under  ordinary  circumstances  would  form  such  tissue. 

Vol.  I.— 16 


242  SURCICAL   PATHOLOGY. 

The  tubercle  is  a  non-vaseular  structure.  Tlie  blood-vessels  wliich 
are  present  in  the  tissue  where  the  tubercle  develops  become  occluded  l)y 
thrombosis  or  from  the  pressure  of  the  numbers  of  cells,  and  no  new 
blood-vessels  make  their  way  into  it. 

This  description  of  tubercle  applies  to  very  young  nodules  in  which 
no  ilcgeneration  has  taken  place.  The  first  evidence  of  such  dcii'cu- 
eration  is  shown  in  hardened  specimens  by  the  nuclei  of  the  cells  in 
the  interior  staining  less  brilliantly.  In  sections  of  fresh  tissue  more 
or  less  extensive  fatty  degeneration  of  the  cells  in  the  centre  is  found. 
The  nuclei  cease  to  stain,  and  the  cells  fuse  together  in  a  solid  homo- 
geneous mass  in  which  no  cell-outlines  can  be  seen.  The  form  of  degen- 
eration is  that  described  by  W'cigert  as  coagulation-necrosis,  and  it  is 
always  preceded  by  fatty  degeneration.  A  zone  of  closely-packed  fat- 
molecules  is  always  found  around  the  necrotic  centre.  In  the  giant-cells 
the  same  process  seems  to  take  place.  The  centre  is  similar  to  the  necrotic 
centre  of  the  tubercle,  and  around  this,  just  inside  the  nuclei,  there  is  a 
zone  of  closely-packed  fat-granules. 

Macrosco])ically,  the  tubercle  when  very  young  is  pale,  transparent, 
and  with  difficulty  distinguished  in  the  tissue.  When  degeneration 
begins  it  is  white,  opaque,  and  easily  seen.  The  white  color  is  not  due 
to  the  absence  of  vessels  alone,  but  rather  to  the  presence  of  the  fat- 
molecules. 

With  the  appearance  of  degeneration  in  the  tubercle  another  cellular 
element  enters  into  it.  This  is  the  polynnclear  leucocyte.  Necrotic  tissue, 
however  caused,  exerts  a  positive  attraction  on  the  leucocytes,  and  the 
necrotic  tissue  in  the  tubercle  has  the  same  power.  The  polynnclear 
leucocytes  may  be  recognized  by  their  irregularity  in  form  and  by  the 
brightness  with  which  they  stain.  They  enter  into  the  tubercle  and  into 
the  necrotic  tissue,  often  forming  a  definite  ring  around  the  latter.  In 
the  degenerated  area  they  seem  to  undergo  the  same  fate  as  the  other 
cells.  The  nuclei  break  up  into  fragments  and  form  the  small,  brightly- 
staining  granules  seen  in  the  tissue.  Occasionally  they  may  be  found 
within  the  giant-cells. 

The  fattv  degeneration  and  caseation  to  which  the  tubercle  is  so 
]nTinc  has  been  attriliuted  principally  to  tiie  absence  of  blood-vessels. 
Although  this  may  play  a  [)art,  the  degeneration  of  the  tissue  cannot  be 
attributed  solely  to  this  cause.  W'c  find  other  structures  in  the  body,  of 
the  same  size  as,  or  even  larger  than,  the  tubercle,  in  which  there  are  no 
vessels  and  which  do  not  show  the  same  tendency  to  degeneration.  The 
necrosis  of  the  cells  is  due  more  to  the  influence  of  the  bacilli  or  their 
chemical  products  on  the  tissue  than  to  the  absence  of  blood-vessels. 

The  relation  of  the  tnlierclc  to  the  surrounding  tissue  differs.  In 
most  cases  there  is  around  it  a  well-marked  zone  of  granulation  tissue 
filled  with  round  cells  which  become  more  abundant  in  the  periphery  of 
the  tubercle,  and  finally  merge  into  the  surrounding  granulation  tissue 
without  a  sharp  line  of  demarcation.  As  the  tubercle  increases  in  size  the 
central  caseation  increases  in  extent  and  the  granulation  tissue  changes 
into  that  of  the  tubercle,  the  round  cells  becoming  epithelioid  in  character. 

The  tubercle  mav  undergo  other  forms  of  degeneration  than  tlie  case- 
ons.  The  entire  mass  may  become  converted  into  a  perfectly  smooth 
hyaline  substance,  or,  before  necrosis  takes  place,  connective  tissue  may 


TUBERCULOSIS  AND   TUBERCLE.  243 

be  formed  from  the  cells,  and  such  tubercles,  even  after  caseation,  are 
nuieli  firmer  and  harder  than  tliose  in  which  tiie  necrotic  tissue  is  com- 
posed of  cells  alone. 

The  number  of  tubercle  bacilli  in  the  tissue  varies;  they  may  be 
present  in  large  numbers  or  may  be  absent  altogether.  As  a  general 
rule,  thev  are  not  so  numerous  in  the  youngest  tubercles  as  they  are  in 
those  in  which  degeneration  is  well  advanced.  In  certain  places  they 
seem  to  be  absent  as  a  rule.  In  acute  miliary  tuberculosis  of  tlie  liver 
I  have  frequently  not  been  able  to  find  a  single  bacillus  in  any  of  the 
numerous  tubercles  in  the  tissue.  It  is  probable  that  under  certain  con- 
ditions thev  are  destroyed  by  the  tissue,  or  they  may  become  so  changed 
as  to  be  no  longer  recognizable.  The  bacilli  occupy  no  constant  position 
in  the  tissue.;  they  may  be  found  within  or  lying  between  the  epithelioid 
cells.  Sometimes  a  mass  of  them  may  be  seen  in  the  centre  of  the  case- 
ous mass,  or  the  giant-cells  may  contain  them  in  varying  numbers. 

The  miliary  tubercles  may  appear  alone,  or  in  numbers  forming  the 
large  conglomerate  tubercles.  Most  of  the  tubercles  which  are  visible 
to  the  naivcd  eye  are  composed  of  several  nodules  united  together. 
These  larger  conglomerate  nodules  are  formed  around  a  single  tubercle 
which  seems  to  serve  as  a  focus  of  infection.  The  tubercle  bacilli  from 
this  are  carried,  either  by  the  lymph-stream  or  enchased  in  wandering 
cells,  into  the  surrounding  tissue,  in  which  numbers  of  tubercles  are  thus, 
developed.  As  the  caseation  in  the  individual  tubercles  advances  it  affects 
also  the  tissue  lying  between  them,  so  that  finally  a  large  caseous  area 
is  formed  which  is  surrounded  by  a  zone  of  miliary  tubercles.  The 
large  solitarv  tubercles  which  are  frequently  found  in  the  lirain,  and  less 
frequenrly  in  the  liver  and  other  parts  of  the  body,  are  formed  in  this 
wav.  Although  the  miliary  tubercle  is  the  most  characteristic  of  the 
lesions  produced  by  the  tubercle  bacillus,  it  forms  but  a  small  part  of 
the  lesions  of  the  disease.  The  formation  of  a  tissue  similar  to  that  of 
the  miliary  tubercle,  and  wiiicii  appears  not  as  a  nodule,  but  as  a  diffuse 
infiltration  of  the  tissue,  is  a  much  more  prominent  part  of  the  process. 
The  formation  of  tliis  tissue  is  closely  related  to  inflammation.  Where 
in  an  ordinary  inflammation  there  would  be  a  formation  of  granulation 
tissue,  under  the  influence  of  the  tubercle  bacillus  a  tissue  composed  of 
epitlielioiil  and  giant-cells,  and  which  is  peculiarly  prone  to  necrosis  and 
caseation,  is  produced.  In  tuberculosis  of  the  joints  the  pale  masses  of 
granulation  tissue  around  tiie  joints  show  on  the  outside  a  narrow  rim 
of  caseation,  and  back  of  this  a  tissue  composed  largely  of  cpitiielioid 
and  giant-cells.  In  this  tissue  there  are  frequently  circumscribed 
tubercles. 

Not  only  is  the  tubercle  in  its  formation  closely  related  to  inflamma- 
tory new  formations  of  tissue,  but  it  is  always  accomj)anied  by  inflam- 
mation. The  nodular  tubercle  as  a  foreign  body  excites  inflammation 
around  it.  The  zone  of  granulation  tissue  around  a  tubercle  is  the 
result  of  a  reactive  inflannnaticm  of  the  tissue.  The  chemical  sub- 
stances which  aj'e  produced  by  the  bacilli  and  in  the  tuberculous  tissue 
may  exert  a  non-specific  but  simply  injurious  action  on  the  surrounding 
tissue,  which  will  l)c  followed  l)y  infianniiation.  The  l)acilli  themselves, 
instead  of  causing  the  more  ty]iical  tissue-formations,  may  excite  inflam- 
mation.     The  form  of  inflanunation  varies.      In   some  cases  an  exuda- 


244  SURdlCAL  PATHOLOGY. 

tion  containing  fibrin  in  v:n ying  amounts  may  1^<'  pnidiiccd  ;  in  otliur 
cases  a  typical  su]>pnratioii.  In  no  otlicr  tissue  in  tiie  body  is  this  inti- 
mate association  witii  intlammation  so  evident  as  in  tiie  lungs.  Apart 
from  the  presence  of  miliary  tubercles,  whicii  ordinarily  ])!ay  but  a 
small  part  in  the  process,  the  lesions  of  pulnKinary  tuberculosis  are 
chiefly  inflammatory.  The  gi-eater  part  of  the  lesions  is  due  to  tuber- 
culous pneumonia,  in  which  there  is  consolidation  of  the  lungs,  due  to 
exudation  and  ac(!Umulation  of  cells  in  the  alveoli.  The  exudation  in 
some  cases  contains  nuich  fibrin  ;  in  otiiers  it  may  be  chiefly  serous,  or 
the  alveoli  may  be  filled  witli  a  hyaline  gelatinous  substance.  The  cells 
witliin  tlie  alveoli  arc  chiefly  large,  jiale,  epithelioid  cells,  mingled  witli 
botli  ^^■hite  and  red  corpuscles.  In  some  cases,  especially  on  serous  sur- 
faces, the  exudation  is  chiefly  hemorrhagic.  Always,  particularly  in  the 
lungs,  along  with  the  inflannnatory  ]>roccsscs  due  directly  to  the  action 
of  the  tubercle  bacilli  and  their  soluble  cliemical  products,  tliere  are 
inflammatory  lesions  due  to  conditions  which  the  l)acilli   create. 

The  inflammatory  tissue  produced  in  the  lungs  l\y  the  l)acilli  under- 
goes the  same  caseation  as  the  tubercle.  It  becomes  converted  into  a 
dry,  homogeneous,  necrotic  mass.  The  fibrin  becomes  enclosed  in  it,  and 
may  still  be  recognized  in  the  caseous  tissue  by  appropriate  methods  of 
staining.  On  microscopic  examination  of  the  brittle  caseous  mass  the 
, anatomical  structure  of  the  tissue  comjiosing  it  may  still  be  recognized. 
In  the  lung  the  walls  of  the  alveoli  ajipear,  dividing  the  caseous  tissue 
into  small  areas.  The  caseation  follows  the  same  course  as  in  the 
tubercle,  commencing  in  the  centre  and  gradually  extending  to  the 
periphery.  An  entire  lobe,  or  even  an  entire  lung,  may  be  converted 
into  a  solid,  necrotic  mass  of  tissue. 

The  caseous  tissue  docs  not  tend  to  remain,  but  after  a  variable  length 
of  time  it  undergoes  softening.  The  cause  of  this  is  not  fully  iniderstood. 
The  dry,  caseous  tissue  becomes  converted  into  a  soft,  fluid,  puriform 
mass.  On  microscopic  examination  fragments  and  detritus  of  tissue  and 
cells  may  be  recognized,  with  here  and  there  a  few  well-preserved  leuco- 
cytes. The  cause  of  the  softening  may  be  due  t(i  changes  taking  jjlace 
in  the  tissue  spontaneously  or  to  the  action  of  influences  from  without. 
The  necrotic  tissue  forms  a  favorable  seat  fi)r  the  action  of  otlier  micro- 
organisms which  can  gain  access  to  it  by  the  bronchi.  The  softening 
may  be  distinctly  purulent ;  there  may  be  a  purulent  inflammation  in  the 
tissue  around  it,  and  the  caseous  matter  may  be  dissolved  in  the  ])urulcnt 
exudation.  As  soon  as  softening  takes  place  favorable  conditions  fiir 
further  infection  are  produced.  Not  f)uly  are  the  tubercle  liacilli  ])rcscnt 
in  the  softened  material,  but  tliere  arc  other  org-anisms.  It  is  probable 
that  even  without  the  presence  of  organisms  the  chemical  products  pres- 
ent may  exert  a  deleterious  influence  on  the  tissues.  Bronchi  always 
open  into  the  softened  area,  and  offer  a  direct  route  for  infection  of  other 
parts  of  the  lungs.  To  the  specific  action  (if  the  various  substances  in 
the  softened  tissues  must  lie  added  the  effects  which  may  be  produced  by 
the  mechanical  action  of  solid  ])articlcs  occluding  the  small  bronchi.  It 
is  easy  to  see  why  in  such  a  tissue  as  that  of  the  lungs  tuberculosis  should 
produce  such  a  variety  of  lesions. 

There  is  probably  no  disease  in  which  there  is  such  a  variety  in  the 
lesions  as  is  found  in  tuberculosis.     A  careful  study  of  the  lung-lesions 


TUBEECVLOSTS  AXD   TUBERCLE.  245 

iu  a  case  of  flirnnie  tulicroulnsis  would  .show  nearly  all  the  patholow'ical 
processes.  The  course  of  the  disease  also  varies.  In  some  cases  it  may 
advance  rapitlly  and  lead  to  death  in  a  few  months  or  even  weeks ;  in 
other  cases  it  jiursues  the  most  protracted  course,  may  contmue  during 
the  entire  life  of  the  individual,  and  in  the  end  only  indirectly  contribute 
to  death.  All  of  these  differences  in  the  effects  of  infection  Avith  the 
bacillus  de|)end  upon  a  number  of  factors. 

All  individuals  are  not  equally  susceptible  to  the  disease.  It  was 
formerly  ii-eni'rally  believed  that  the  disease  itself  was  mherited,  bnt  it  is 
more  jVrobable  that  not  the  disease  itself,  but  a  greater  or  less  suscep- 
tibilitv  to  the  disease,  is  inherited.  Other  things  being  equal,  children 
of  tul)erculous  parents,  especially  if  the  disease  has  been  in  the  family  for 
a  nund)er  of  generations,  are  more  liable  to  be  aflected  with  tulierculosis 
than  the  children  of  parents  who  were  free  from  this  disease.  This 
S])ecial  susceptibility  or  tendency  may  not  be  expressed  in  any  other 
weakness  or  habit  of  the  body  :  such  children,  born  of  parents  in  good 
circumstances  of  life,  may  develop  strong  and  robust  bodies  with  more 
than  the  average  powers  of  endurance.  One  factor  must  always  l)e 
considered — nam^'ly,  that  in  general  these  children  have  greater  opjior- 
tunities  for  infection  if  they  are  living  in  the  house  with  tuberculous 
people.  It  is  also  probable  that  certain  races  show  a  greater  susceptibility 
than  others  to  this  disease.  In  this  country  certainly  the  colored  and 
the  Celtic  races  seem  to  be  m(n-e  liable  to  the  disease  than  any  other, 
while  the  Jewish  race  appears  to  possess  a  certain  degree  of  innnunity 
against  it.  The  same  thing  is  true  of  cattle.  The  cattle  coming  from 
the  Channel  Islands,  the  Alderney  and  Jersey  stock,  especially  the  pure 
breeds,  have  much  more  of  the  disease  among  tlieni  than  any  other 
breeds. 

It  is  probable  that  there  are  also  differences  in  the  virulence  of  the 
bacilli  iu  different  cases.  Even  inoculations  on  guinea-pigs  of  the  same 
age  with  the  same  amounts  of  virus  from  different  sources  show  differ- 
ences in  the  course  of  the  disease. 

The  course  of  the  disease  will  further  be  influenced  by  the  manner  in 
which  the  organisms  gain  entrance  into  the  tissue.  They  may  enter 
it  bv  means  of  canals  or  ducts  which  commimicate  with  the  outside, 
or  by  the  blood-  and  lymphatic  vessels.  In  this  way  either  tuberculous 
iniiannnations  or  miliary  tulierdes  may  be  produced.  It  is  probably 
not  necessary  to  have  an  actual  lesion  of  continuity  for  the  bacilli  to 
pass  into  the  tissue.  It  has  been  shown  that  the  disease  can  be  produced 
by  rubbing  the  organisms  on  the  skin  of  a  rabbit.  Tuberculosis  of  the 
aiimentary  canal  in  man  probably  takes  place  without  any  preceding 
lesion.  The  tubercles  here  a])])ear  first  in  tlie  lymj)h-glandular  tissue  of 
the  gut,  and  no  lesifm  of  the  mucous  surface  may  be  visil)le.  Not  only 
is  there  a  general  difference  in  the  susceptiliility  of  the  tissue  of  different 
individuals,  but  there  are  differences  in  the  different  tissues  of  the  same 
individual.  Some  tissues  are  almost  exempt.  In  certain  cases  tubercle 
bacilli  may  be  found  in  great  quantities  in  the  blood,  and  miliary  tuber- 
cles be  formed  all  over  the  body,  except  in  the  muscles.  The  ovary 
shows  a  relative  immunity,  and  the  ])ancreas  and  thyroid  are  rather 
rarely  attacked.  It  canuot  be  tliat  these  organs  are  jirotected  from  the 
entrance  of  the  bacilli,  f  )r  in  cases  of  infection  by  the  l)lood  they  are 


246  SURGICAL  PATHOLOGY. 

equally  liable  to  have  the  bacilli  carried  into  them.  None  of  the  tissues 
enjoy  an  absolute  immunity.  Even  the  muscles  may  be  invaded  by  the 
gradual  extension  of  tuberculous  foci  into  them.  In  a  tuberculous  uleer 
of  the  tongue  tubercles  are  found  in  the  nniscular  tissue  for  :|uite  a  long 
distance  l)cneath  tlu'  ulcer.  In  cases  of  joint  tulicrculosis  also  the  adjacent 
muscles  may  be  involved  by  the  extension  of  tiie  disease. 

There  is  always  some  primary  focus  of  the  tlisease  in  the  body.  The 
primary  seat  of  the  disease  in  most  eases  is  in  the  lungs,  but  it  may  com- 
mence in  almost  any  other  organ  of  the  body.  From  the  primary  foens 
the  infection  extends,  following  various  routes.  There  may  be  infection 
of  the  tissues  in  direct  continuity.  The  bacilli  may  be  carried  enclosed 
in  cells,  or  they  may  extend  by  growth  into  the  tissue  adjoining,  and  in  this 
way  large  tubercuhms  nodules  may  be  formed.  The  bacilli  may  pass 
along  the  lymphatics,  either  into  the  surrounding  tissue  or  into  the 
lymphatic  glands  into  which  the  lymph-vessels  empty.  The  infection 
of  the  lymphatic  glands  almost  surely  takes  place,  and  in  many  cases 
they  may  jn-esent  the  oidy  evidence  of  the  disease.  In  tiU)crculosis  of 
the  lungs  the  bronchial  glands  are  always  aifected  :  if  the  intestine  be 
aflected,  the  mesentery  glands  are  tul)erculous.  In  many  eases  the 
bacilli  are  probably  carried  directly  to  the  lymph-glands  from  the  seat 
of  entry  without  producing  any  lesions  where  they  have  entered.  It  is 
probable  that  in  many  eases  the  bacilli  gain  entrance  into  the  tissues 
through  the  nnicous  membrane  of  the  mouth  or  ])harynx,  and  the  first 
evidence  of  the  disease  is  in  the  cervical  glands.  The  glands  appear  to 
protect  the  organism  from  further  infection  for  some  time.  The  tissue 
of  the  lymphatic  glands  offers  a  suitable  locality  for  the  growth  of  the 
bacilli.  Extensive  lesions  are  produced  in  them,  a.nd  tinally  the  glands 
serve  as  foci  for  further  infection.  The  glands  next  in  ordci»  become 
affected,  and  in  this  way  all  the  lym])hatics  and  lyinj)h-glaiids  up  to  the 
thoracic  duct  may  graduallv  become  tubercidous  ;  and  finally  the  l)acilli 
are  carried  directly  into  the  bk)od.  In  most  cases  the  infection  follows 
in  the  direction  of  the  lymph-current,  but  it  m'ay  also  proceed  against 
the  stream. 

Infection  may  also  take  place  by  the  bacilli  being  carried  along 
open  canals  or  duets  from  one  ])art  of  an  organ  to  another  or  to  various 
parts  of  the  body.  The  lungs  otfcr  the  most  suitable  conditions  for  this 
mode  of  infection.  The  jirimary  seat  of  the  disease  in  most  eases  is  in 
the  apices,  and  when  softening  of  the  caseous  tissue  takes  j)lace  the 
detritus,  full  of  bacilli,  may  be  carried  by  aspiration  into  every  other 
part  of  the  lungs.  The  bacilli  are  contained  in  the  sputum,  and  further 
infection  both  of  the  air-passages  and  of  the  alimentary  canal  takes  place 
from  this. 

This  mode  of  infection  is  seen  also  in  the  genito-urinary  tuberculosis 
in  the  male.  Here,  in  the  majority  of  cases,  the  ])rimary  seat  of  the  dis- 
ease is  in  the  epididymis.  It  may  be  confined  to  this,  or  the  testicle  may 
be  affected  by  continuity.  The  e]iidi(lymis  is  converted  into  a  more  or 
less  firm,  caseous  mass.  From  this  the  disease  extends  along  the  vas 
deferens,  which  becomes  enlarged,  and  on  section  the  interior  is  found  to 
be  lincil  with  a  whitish  caseous  tissue.  In  both  the  vas  deferens  and  epi- 
didymis the  seat  of  the  disease  is  primarily  in  the  epithelium  and  takes  the 
form  of  a  tuberculous  inflammation.    The  seminal  vesicles  on  the  same  side 


TUBERCULOSIS  ASl)   TUBERCLE.  247 

lieeonie  affoctod  in  uidst  cases,  or  they  may  be  passed  by  and  tlie  disease 
appear  in  tlie  prostata  ov  Ijladder.  l^^p  to  this  point  it  is  easy  to  see  how 
tlie  infection  has  taken  phice  :  the  extension  has  been  in  the  direction  of 
the  secretion,  and  the  l)ai'illi  eonUl  be  carried  ah)ng  with  the  secretion. 
From  the  bladder  the  extension  is  in  a  direction  opposite  to  the  flow  of 
the  secretion.  With  or  withont  any  involvement  of  the  ureter  infection 
of  the  pelvis  of  the  kidney  and  of  the  adjoining  kidney -tissue  takes  place. 
It  is  prolialde  that  the  bacilli  And  suitable  conditions  for  growth  in  the 
ureter,  and  grow  along  the  walls,  just  as  on  the  surface  of  a  solid  medium, 
until  the  pelvis  of  the  kidney  is  reached.  There  is  no  other  way  for 
infection  to  take  place  from  the  bladder  to  the  kidney  than  along  the 
ureter.  There  is  no  lymphatic  or  vascular  connection.  The  proof  that 
this  is  the  usual  route  of  infection  in  genito-urinary  tuberculosis  is  shown 
by  the  certainty  with  wliicli  the  <lisease  can  be  traced  step  by  step,  and 
the  extreme  rarity  of  the  disease  in  females  as  compared  Avith  males. 
In  some  cases  the  tlisease  appears  to  l3e  primary  in  the  kidney,  and  the 
infection  may  take  place  in  the  opposite  direction. 

The  blood  plays  an  important  j)art  in  the  extension.  Sometimes  the 
bacilli  gain  entrance  into  the  blood  from  tlie  lym])liatics.  The  more  com- 
mon wav  is  by  a  direct  infi'ction  of  the  blood.  Tuberculosis  of  some  of 
the  large  veins  of  the  l)ody  may  take  place,  the  vein  being  atlectcd  l)y  the 
extension  of  a  tubi'rcuious  process  in  an  adjoining  tissue.  The  bacilli  are 
carried  by  the  blood  into  all  the  organs  of  the  body,  and  a  general  miliary 
tuberculosis  is  the  result.  Even  in  this  some  of  the  tissues  are  exempt. 
Miliary  tubercles  are  never  found  in  the  muscles  or  in  the  skin,  and 
only  rarely  in  the  alimentary  canal  or  in  the  ovaries.  Infection  by 
tlie  blood  may  take  ]>lace  without  the  production  of  a  general  miliary 
tul)er<'ulosis.  In  almost  every  case  of  extensive  tuberculosis  a  few 
tubercle  bacilli  probably  enter  into  the  blood.  These  will  be  dcjwsited 
chiefly  in  those  organs  in  which  the  conditions  of  the  circulation  are 
most  favorable  for  the  retention  of  fine  solid  particles.  The  liver  offers 
the  most  suital)lc  conditions  for  this,  and  in  every  case  careful  search 
will  siiow  the  presence  of  a  few  tubercles  in  this  organ.  In  some  cases 
the  bacilli  may  apparently  gain  access  to  the  blood  without  j)rodncing 
any  other  lesions.  From  the  primary  infection  they  may  in  some  way 
gain  entrance  into  the  blood  and  be  dejjosited  in  various  organs.  In  no 
other  way  are  we  able  to  explain  the  ]irimary  tuberculosis  of  the  bones 
and  other  organs  into  which  tiiey  could  have  been  carried  only  by  the 
blood. 

Of  late  the  theory  of  congenital  tuber'culosis,  the  result  of  intra- 
uterine infection,  has  received  more  credence  than  formerly.  Bauni- 
garten  particularly  iqiholds  tliis  view,  and  explains  in  this  way  certain 
cases  in  which  the  infection  ij  otherwise  obscure.  In  a  few  cases  con- 
genital tuberculosis  has  been  proven  beyond  doubt  both  in  animals  and 
in  man.  The  first  case  in  whicli  this  was  siiown  was  in  the  organs  of  a 
fVetal  calf,  and  careful  investigation  has  shown  that  this  condition  is  not  so 
very  uncommon.  Baumgarten  found  a  caseous  tubcrcidous  noilule  in  the 
cervical  vertebra  of  a  stillborn  infant.  Birch-Hirschfeld  found  tubercle 
bacilli  in  a  seven  months'  fretus  and  placenta  removed  by  Csesarcan  sectioti 
from  a  mother  affected  with  general  miliary  tuberculosis.  The  bacilli 
were  demonstrated  both  by  direct  examination  and  by  the  inoculation  of 


248  SURGICAL  PATHOLOGY. 

giiiiic'a-])if!;s.  Cases  of  tuberculosis  in  infants  dying  the  first  few  days 
or  weeks  after  birtli  are  not  so  very  uncommon,  and  many  of  tliese  eases 
sliould  be  regarded  as  due  to  inti'a-uterine  infection,  (xiirtner  lias  found 
that  transmission  of  tultercle  bacilli  from  the  inother  to  the  fa^tus  is  not 
very  uncommon  in  mice,  canary  birds,  and  rabbits.  Nor  is  the  infre- 
quency  of  tuberculosis  in  new-born  children  and  infants  a  conclusive 
argument  aga'nst  intra-uterine  infection.  The  infection  may  take 
place  in  intra-uterine  life,  and  the  disease  remain  latent  for  a  number 
of  years. 

The  question  as  to  the  frequency  of  directly  inherited  or  congenital 
tuberculosis  must  be  consideri'd  in  connection  witli  the  fact,  referred  to 
above  (p.  245),  that  the  children  of  a  tuberculous  jiarent  usually  live  in 
a  house  or  room  which  is  more  or  less  infected  with  the  specific  bacilli 
derived  from  the  sputa  of  the  parent,  and  hence  are  more  than  usually 
liable  to  contract  the  disease. 


GENERAL  BACTERIOLOGY  OF  SURGICAL 
INFECTIONS.  ^' 

By  WILLIAM  H.  WELCH,  M.  D, 


INTEirBERS  of  each  of  the  three  groups  of  pathogenic  micro-organisms 
— bacteria,  fungi,  and  protoztia — may  (;ause  surgical  infeotions.  Fungi 
and  protozoa,  however,  are  far  less  commonly  concerned  in  these  infec- 
tions than  are  bacteria.  In  a  general  consideration  of  the  conditions  of 
surgical  infection  bacteria  are  the  organisms  which  require  chief  atten- 
tion, so  that  the  subjects  to  be  considered  in  this  article  can  be  appro- 
priately inchuled  under  the  designation  "  General  Bacteriology  of  Surgi- 
cal Infections." 

Tlie  term  "  general  bacteriology "  is  here  used  in  distinction  from 
"  special  bacteriology  "  to  designate  the  general  relations  of  bacteria  to 
surgical  infections.  It  is  not  deemed  necessary  in  this  article  to  enter 
into  a  detailed  consideration  of  the  mor})iiological  and  cultural  charac- 
ters of  bacteria.  This  subject  is  fully  treated  in  \\x)rks  especially  devoted 
to  bacteriology. 

Infectious  diseases  which  require  especial  consideration  by  the  sur- 
geon include,  on  the  one  hand,  many  specific  infections,  such  as  tubercu- 
losis, tetanns,  glanders,  anthrax,  and  actinomycosis,  and,  on  the  other 
hand,  traumatic  and  other  inflammatory  and  septic  infections  caused  by 
various  widely-distributed  bacterial  sjiecies. 

The  specific  infectious  diseases,  such  as  tul)erculosis,  tetanus,  etc.,  are 
for  the  most  part  sliarply  differentiated  by  their  anatomical  and  clinical 
characters,  and  are  caused  by  micro-organisms  which  are  constantly  and 
exclusively  associated  witli  their  respective  diseases. 

On  the  other  hand,  the  common  traumatic  infections  and  other  sur- 
gical inflammations  and  septic  processes  do  not  jiresent  eqtially  sharp  and 
dcfiniti'  differential  characters,  and  aj)parently  identical  or  similar  patho- 
logical processes  belonging  to  this  gi'onj)  of  affections  may  be  caused  by 
various  micro-organisms.  Thus  we  do  not  find  in  such  diseases  as  septi- 
cemia, pyaemia,  abscesses,  osteomyelitis,  puerperal  fever,  or  other  septic 
and  localized  inflammations,  or,  in  general,  in  the  infections  of  wounds, 
any  single  bacterial- species  eunstantly  and  exclusively  associated  with 
eacii  of  tiiese  affections,  but  each  disease  of  this  group  may  be  caused 
by  more  tiian  one  species  of  micro-organism. 

The  etiology  of  these  common  septic  and  inflammatorj'  affections 
presents  for  our  consideration  many  jiroblems  quite  distinct  from  tliose 
pertaining  to  the  causation  of  the  specific  infections.  The  views  now  held 
as  regards  sources  of  infection,  o])erative  ])rocedurcs,  and  tlie  manage- 
ment of  wounds  have  been  developed  largely  as  the  I'esult  of  investiga- 
tions concerning  the  relation  of  bacteria  to  traumatic  infections. 

249 


250       GENERAL  BACTERIOLOGY  OF  SURGICAL  INFECTIONS. 

It  is  important  tliat  the  surgeon  should  become  familiar  with  the 
various  kinds  of  bacteria  concerned  in  surgical  infeotioris,  with  their 
distribution  on  exposed  surfaces  of  the  body  and  in  the  outer  world, 
witli  tlie  ways  by  which  they  may  cntci'  and  be  (lisciiarge(l  IVum  the 
body,  witli  tile  various  conditions  Mliich  favor  their  invasion  and  uiulti- 
])!ication  in  the  body,  with  their  jiathogenic  manifestations,  and  with 
the  means  of  combating  them.  It  is  proposed  in  this  article  to 
present  the  more  important  considerations  pertaining  to  these  .sub- 
jects so  for  as  they  do  not  fall  more  appropi'iately  for  their  treatment 
to  other  sections  of  this  ^\'oi-i<. 

We  shall  consider  tirst  the  disti'il)ution  of  bacteria  on  ex])os('d  sur- 
faces of  the  body,  liaving  especially  in  view  its  surgical  l)earings. 
Knowledge  of  the  distribution  of  pathogenic  bacteria  is  of  importance 
in  the  study  of  the  causation  of  surgical  infections,  as  indeed  of  all 
infectious  diseases. 

Bacteria  of  the  Skin. 

There  are  various  questions  of  surgical  interest  relating  to  the  bacteria 
of  the  skin.  The  destruction  of  the  surface  bacteria  both  on  the  hands 
of  the  operator  and  his  assistants  and  over  the  field  of  operation  in  the 
patient  is  of  fundamental  importance  in  surgical  techni(pie.  It  is 
important  to  determine  the  possibilities  of  danger  from  infection  by 
bacteria  commonly  or  occasionally  found  in  or  on  the  skin.  Ignorance 
of  the  bacterial  flora  of  the  normal  skin  has  led  some  investigators  to 
erroneous  interpretations  of  their  observations  as  to  the  source  of  bacteria 
found  in  wounds  treated  aseptically  or  antiseptically,  and  as  to  the 
presence  of  supposed  specific  ]>athogenic  bacteria  in  certain  cutaneous 
diseases. 

The  micro-organisms  of  the  human  skin  have  been  studied  by  several 
investigators,  of  whom  may  be  mentioned  Bizzozero,  Bordoni-Uffrcduzzi, 
Unna,  IMaggiora,  Mittmann,  Fiirbringer,  Preindlsberger,  Robb  and 
Ghriskey,  and  "Welch." 

As  the  skin  is  exposed  to  contamination  from  the  air  and  all  sorts 
of  sources,  it  is  evident  that  there  is  scarcely  any  limit  to  the  number 
of  species  of  bacteria  which  may  possibly  be  found  on  the  skin.  Most 
investigators  of  this  subject  have  not  had  the  patience  or  have  not  thought 
it  worth  while  to  attempt  to  itlcntify  or  to  describe  all  of  the  various  kinds 
of  bacteria  developing  in  cultures  from  the  surface  of  the  skin.  Mitt- 
mann mentions  seventy-eight  different  species  of  cutaneous  bacteria,  of 
Avhich  fifty-six  were  cocci.  His  descriptions,  however,  are  so  imperfect 
as  scarcely  to  serve  for  the  identification  of  the  species.  Preindlsberger 
describes  thirty-two  species,  of  which  twenty-eight  were  cocci.  Maggiora 
isolated  twenty-nine  micro-organisms,  of  which  twenty-two  were  bacteria, 
thi'ee  budding  fungi,  and  four  moulds.     ]\Iost  of  these  bacteria  are  such 

'  Bizzozero,  Virchow's  Archii;  Bd.  iKS ;  Bordoni-Uffreduzzi,  Fortxchnfte  der  Medk'm, 
1886,  p.  151  ;  Unna,  Monati:hefte  J'ilr  pnd-liselie  Dermntnlogie,  1889,  1S90,  1891  ;  Maggiora, 
Oiornalc  delta  R.Socktd  d'Igiene,  1889;  Mittm.inn,  Vircliou^s  Archil;  Bd.  113;  Fiirbringer, 
Desinfektion  d.  Hlinde  d.  Arstes,  Wiesbaden,  1888  ;  Preindlsberger,  Zur  Kcnnttiiiis  der  Rac- 
terien  dex  Unternagelraumeft  u.  s.  v.,  AVien,  1891  ;  Rol)b  and  Gliriskey,  Johns  Hophins 
Hospital  Bulletin,  April,  1892 ;  Welch,  Trans,  of  the  Congr.  of  American  Physicianis  and 
Surgeons,  vol.  ii.,  and  Maryland  Medical  Journal,  Nov.  14,  1891. 


BACTERIA    OF  THE  SKTX  251 

as  arc  often  found  in  the  air  oi-  on  external  objects.     Cocci  are  usually 
found  much  more  abundantly  than  bacilli  in  cidtures  from  the  skin. 

(Jreat  variations  exist  in  different  cases  as  to  the  kinds  and  the 
number  of  bacteria  found  on  the  skin.  Sometimes  one  species  prcxlomi- 
nates  over  the  rest,  indicating  that  it  has  multi})licil  and  overgrown  other 
bacteria.  The  conditions  in  general  are  not  favorable  for  the  growth  of 
bacteria  on  the  surface  of  the  skin,  but  under  the  nails  and  in  situations 
where  moisture  collects,  as  in  the  axillie,  the  groins,  and  between  the  toes, 
there  mav  be  abundant  nudtiplication  of  certain  species  of  micro- 
organisms. Altiiough  Ixictcria  [)rcdoniiuate,  budding  and  mould  fungi 
are  often  present.  The  large  mmibcr  of  micro-organisms  which  accu- 
mulate beneath  the  nails  is  a  matter  of  surgical  importance.  From  a 
minute  particle  of  material  from  this  situation  sometimes  as  many  as  two 
thousand  to  five  thousand  colonies  develop  in  culture  media,  although 
Usually  tlu-  number  is  nuich  less,  an<l  may  lie  very  small  indeed,  perhaps 
not  more  than  tiu'ee  or  four  colonics. 

The  writer  in  1891  was  the  first  to  call  attention  to  the  fact  that, 
although  in  aeneral  the  bacterial  flora  of  the  skin  is  inconstant  and  indef- 
inite  in  its  s})ecial  characters,  there  is  one  bacterial  species,  to  which  he 
gave  the  ntunc  of  xfitjjlii/fococcu.x  cpUhrinidis  alhux,  which  is  found  with 
such  regularity  in  cultures  from  the  skin  that  it  may  properly  be  regarded 
as  a  regular  iniialiitant  of  tlic  normal  skin,  just  as  the  bacillus  coli  com- 
munis is  a  regular  inhabitant  of  the  intestinal  canal.  The  principal  data 
relating  to  this  staphylococcus  were  established  by  the  researches  of  Robb 
and  Ghriskey.  We  consider  this  coccus  to  be  a  variety  of  the  staphy- 
lococcus jiyogcnes  albus.  It  is  possessed  of  feeble  pyogenic  power,  and 
usually  li(piefics  gelatin  and  coagulates  milk  more  slowly  than  the  ordi- 
nary white  pyogenic  stajiliylococcus.  For  these  reasons,  but  especially 
to  emphasize  the  epidermis  as  a  normal  haliitat  for  this  organism,  we 
applied  the  designation  mentioned. 

One  of  the  chief  points  of  interest  relating  to  this  coccus  is  that  it  is 
very  often,  prolialjly  regularly,  present  in  lavers  of  epidermis  along  tiie 
hair-shafts,  deeper  than  can  be  reached  by  any  known  means  of  cuta- 
neous disinfection  save  tlie  application  of  iicat.  After  complete  sterili- 
zation of  the  surface  of  the  skin,  so  that  scrapings  are  sterile  when 
inoculated  into  culture  media,  the  presence  of  this  white  coccus  can  still 
bo  demonstrated  by  making  cultures  from  sutures  passed  through  the 
skin  or  from  excised  pieces  of  skin. 

Tlie  sta])hylococcus  epidermidis  albus  is  usually  innocuous.  It  is  found 
frequently  in  aseptic  wounds  of  the  skin  without  causing  sup]>uration  or 
any  trouble.  The  source  of  this  coccus  in  asejitic  wounds  does  not  seem 
to  be  kno\vn  to  many  who  have  made  bacteriological  examinations  of 
such  wounds;  thus.Budingerj^  who  examined  in  1892  twenty  operative 
wounds  which  healed  by  first  intention  in  Bilh-oth's  clinic,  could  not  sug- 
gest any  other  origin  i'nr  its  presence  than  the  air,  and  C.  Fracnkel-  sug- 
gests that  it  is  lirought  to  the  wound  by  the  blood-current — suggestions 
W'hich  were  rendered  <|uite  unnt'ccssary  I)y  our  previous  researches. 

Although  this  white  e])idermal  staphylococcus  is  often  found  in 
w'ounds  without  any  disturban(;e  in  the  process  of  healing,  it  may  be 

'  Biidinger,  Wiener  klin.  Woehemidir.,  1892,  Nos.  22,  24,  25. 
^  C.  Fraenkel,  Baumqarlen' s  Jahresberichl,  1892,  p.  28. 


252       GENERAL  BACTERIOLOGY  OF  SURGICAL  INFECTIONS. 

the  cause  of  some  disturbance,  diaractcrized  especially  by  elevation  of 
temperature  and  moderate  sn])puration.  This  is  particularly  likely  to 
be  the  case  when  there  is  necrotic  or  stranjjulated  tissue  in  the  wound  qv 
when  foreio'ii  bodies  have  been  introduced  into  the  wound.  It  is  a  com- 
mon, altiiough  not  the  sole,  cause  of  stitch-abscesses,  and  it  is  prone  to 
travel  down  along  the  sides  of  a  drainage-tube,  and  under  these  circinn- 
stances  may  cause  the  wound  to  sujipurate.  It  is  often  associated  with 
other  pyogenic  cocci  in  cutaneous  inflammations.  We  can  now  under- 
stand how,  without  any  flaw  in  the  antisejttic  technique  of  the  surgeon, 
tiiis  micro-organism  may  be  present  in  wounds,  and  we  have  a  satis- 
factory explanation  of  the  frequent  occurrence  of  stitch-al)scesses. 

This  white  skin-coccus  is  often  present  in  cultures  from  blood  ob- 
tained by  jjuncture  of  the  human  skin  and  in  cultures  from  the  sweat 
after  complete  disinfection  of  the  surface  of  the  skin.  Some  observers 
seem  to  have  supposed  that  when  the  stapliylococcus  albus  is  demon- 
strated under  these  conditions  its  presence  in  the  circulating  Idood  or  its 
excretion  by  the  sweat-glands  can  be  inferred.  But  it  is  evident  that 
such  an  inference  is  unwarranted  without  additional  proof. 

There  are  various  other  white  cocci,  and  also  several  species  of  yel- 
low cocci,  both  liquefying  and  non-liquefying,  which  are  frequently 
found  in  cultui'es  from  the  skin.  Some  of  the  yellow  cocci  can  readily 
be  mistaken  for  the  sta]diylococcus  pyogenes  aureus,  unless  they  are 
carefully  studied  in  culture  m(>dia.  Tlie  staphylococcus  pyogenes  aureus 
may  be  found  on  the  skin,  as  will  be  mentioned  presently. 

The  kinds  and  the  number  of  bacteria  found  upon  exposed  parts  of 
the  skin  vary  considerably  according  to  the  habits  and  the  occupation  of 
the  individual.  Of  especial  interest  in  this  connection  are  the  results  of 
the  examination  of  the  skin  of  surgeons  and  others  who  come  into  con- 
tact with  infected  persons  either  during  life  or  at  the  autopsy-tal)le.  We 
have  found  only  exceptionally  the  Maph)iIococcux  piior/ciics  aureus  upon 
the  hands  of  those  Mho  do  not  come  into  proximity  to  surgical  or  infected 
cases,  Avhereas  we  have  many  times  found  this  micro-organism  upon  the 
hands  of  surgeons,  their  assistants,  and  surgical  nurses.  In  examining 
the  hands  of  those  who  use  corrosive  sublimate  as  a  disinfectant  it  is 
necessary  first  to  neutralize  the  sublimate  with  ammonium  sulpiiide,  as 
we  have  found  that  tiie  sublimate  may  prevent  the  development  of  cuta- 
neous micro-organisms  with  which  it  has  come  into  contact,  although  it 
has  not  killed  them  ;  and  this  restraining  influence  may  be  manifest  days, 
and  even  weeks,  after  the  application  of  the  sublimate. 

The  length  of  time  that  the  yellow  pyogenic  staphylococcus  may 
persist  upon  the  hands  varies,  and  doubtless  largely,  according  to  the 
methods  and  extent  of  cleansing  tiie  skin.  It  certainly  may  i>crsist  for 
several  days,  although  it  may  disappear  in  a  few  hours.  It  does  not 
seem  usualh^  to  grow  down,  as  does  the  white  epidermal  coccus,  into 
the  deeper  layers  of  the  skin,  so  that  ordinary  methods  of  disinfection 
of  the  skin  are  likely  to  remove  or  destroy  this  organism.  By  rubbing 
or  by  the  application  of  pressure  the  stajihylococcus  aureus  may,  how- 
ever, be  pressed  into  the  deeper  layers,  jwrticularly  into  the  liair-f()llicles, 
and  there  cause  furuncles,  as  has  lieen  shown  liy  the  experiments  of 
Garre,  Schimmelbusch,  Wasmuth,  and  others.  The  view  which  has  been 
advocated  by  some  writers  that  it  requires  more  thorough  disinfection  to 


BACTERIA   OF  THE  SKIN.  253 

remove  or  destroy  patliogonie  baeteria  accidentally  or  intentionally  ap- 
jilicd  to  the  skin  than  tt)  kill  the  ordinary  liacteria  of"  the  skin  is  not 
snpported  liy  ex])erinieiits.  Tiie  healthy  skin  in  i^eneral  is  not  a  favor- 
able resting-  or  breeding-place  to  secure  tlie  long  persistence  of  patho- 
genic bacteria,  with  the  exception  of  the  white  epidermal  coccus,  which 
possesses  relatively  little  pathogenic  power  under  ordinary  circumstances. 

The  stirptocoecm  pyogenes  has  been  found  less  frequently  than  the 
staphylococcus  aureus  in  cultures  from  the  skin,  and  liere  too  chieHv  in 
cultures  from  the  skin  of  infected  patients  or  of  those  who  have  been  in 
jjroximity  to  them.  It  is  well  to  bear  in  mind  that  these  pvi)genic  cocci 
are  not  necessarily  limited  to  the  immediate  neighborhood  of  an  infected 
wound  or  focus,  but  may  occur  on  other  parts  of  the  body,  as  well  as  in 
the  air  or  on  objects  which  have  been  near  the  patient.  Thus  Preindls- 
berger  found  the  aureus  in  the  dirt  beneatli  tiu'  finger-nails  of  a  patient 
with  fracture  of  tlie  femur,  and  the  streptococcus  jiyogenes  in  the  same 
situation  in  a  patient  with  osteomyelitis  femoris  for  which  necrotomy 
had  been  performed.  The  complete  disinfection  of  an  infected  wound, 
even  if  that  were  possible,  would  not  therefore  furnish  a  guarantee  that 
pyogenic  cocci  were  not  present  upon  the  surface  of  the  patient's  body 
in  other  situations. 

The  hdciUii!^  pi/oeyaneuf!  is  a  common  parasite  upon  the  human  skin. 
Miihsam'  found  it  in  the  axilla  and  in  the  anal  and  inguinal  folds  of 
hetdthy  persons  iu  50  per  cent,  of  the  cases  examined.  Probably  local 
conditions  were  concerned  in  these  observations,  as  others  have  not 
found  this  organism  upon  the  healthy  skin  with  such  frequency.  Al- 
though tliis  organism  may  manifest  importaTit  pathogenic  activities,  its 
])resc'uce  in  wounds  is  usually  made  evident  chiefly  by  the  green  or  blue 
discoloration  of  the  dressings.  It  was  formerly  sujjposed  to  enter  the 
wound  from  the  air,  but  it  doubtless  is  often  derived  also  from  the  skin 
of  the  patient. 

The  common  intestinal  bacterium,  the  hdciUiix  co/i  commnnls,  is  of 
course  often  present  on  the  skin  about  the  anus.  In  abscesses  in  this 
situation  it  is  often  found  either  alone  or  associated  with  otlier  bacteria. 
The  colon  bacillus  may  also  l)e  found  ujion  the  skin  in  other  parts  of 
the  body.  It  is  a  widely-distributed  bacterium  outside  of  the  animal 
body.  It  has  repeatedly  been  found  in  wounds  in  different  parts  of 
the  body. 

Skin  contaminated  with  the  soil,  whicli,  as  is  well  known,  contains 
in  many  situations  abundant  Itacilli  of  tetanus  and  of  malignant  cedema, 
is  likely  to  present  these  micro-organisms.  This  contamination  relates, 
of  course,  especially  to  the  hands,  and  in  the  case  of  those  who  go  bare- 
foot or  have  holes  in  their  shoes  also  to  the  feet.  Maggiora  M'as  able  to 
demonstrate  the  bacillus  of  malignant  cedema  in  scrapings  from  between 
the  toes  of  a  jierson  who  had  walked  for  half  an  honr  in  a  garden  with 
a  torn  shoe.  It  is  not  therefore  in  all  cases  necessary  to  sujtpose  that 
the  tetanus  I)acillus  enters  a  wound  from  the  object  which  causes  the 
wound,  for  tiiis  bacillus  may  previously  have  been  attached  to  the  skin. 
It  may  in  this  connection  be  mentioned  that  the  fseces  of  herbivorous 
animals  often   contain  the   tetanus    bacillus,  and    in  a  condition   more 

'  Miihsam,  cited  by  Schimmelbusch,  Sainml.  klinischer  Vortrdge  von  Vothnann,  Serie  3, 
Heft.  ii.  No.  62. 


254       GENERAL  BACTERIOLOGY  OF  SURGICAL  INFECTIOyS. 

likely  to  produce  tetanus  than  when  tlio  bucillus  is  obtained  from  the 
soil.  Buday  '  has  reported  a  case  of  tetanus  fatal  in  twentv-four  liotu-s 
which  followed  the  smearing  of  a  wound  v.itli  fa'ces. 

The  .sintyma  /mu-I/Iks  may  l)e  considered  in  connection  with  the  cuta- 
neous bacteria.  Tiiis  l)acterium  is  usually  present  in  the  smegma,  and 
may  be  found  about  the  penis,  scrotum,  vulva,  and  anus.  iVttention 
was  first  called  to  this  bacillus  by  Alvarez  and  Tavel  and  \)y  Mattei- 
stock  in  1886,  on  account  of  its  resemblance  in  morphology  and  staining 
reactions  to  Lustgarten's  bacillus,  which  at  that  time  was  thftught  by  its 
discoverer  to  be  tlie  specific  cause  of  syphilis.  Greater  practical  impui-f- 
ance,  however,  belongs  to  the  smegma  Ixicillus  at  present  on  account  of 
the  possibility  of  mistaking  it  from  its  staining  properties  for  the  tuber- 
cle bacillus,  and  there  is  reason  to  believe  that  such  mistakes  liave  been 
made  in  examinations  of  the  urine  and  of  secretions  or  exudates  about 
the  external  genitals  and  the  anus.  The  smegma  bacillus  resembles  the 
tubercle  bacillus  in  th(>  ])niperty  of  rt'taiuing  the  staining  dye  after  such 
application  of  acids  and  alciihul  that  all  known  bacteria  except  the  tu- 
bercle bacillus,  the  smegma  bacillus,  and  the  leprosy  bacillus  ai'e  decol- 
orized. This  property  probably  does  not  inhere  in  the  smegma  bacilli 
as  such,  but  is  due  to  the  presence  of  chemical  constituents  of  the 
smegma,  although  this  jioint  is  not  positively  settled.  In  the  opinion 
of  the  writer  this  peculiar  staining  reaction  does  not  belong  to  onlv  a 
single  species  of  bacillus  in  the  smegma,  but  to  several,  so  that  it  is 
more  proper  to  speak  of  smegma  bacilli  with  this  reaction.  Mistakes 
are  particularly  likely  to  occur  when  the  handy  and  popular  Gabbet's 
stain  for  the  tubercle  bacillus  is  emjiloyed.  The  usual  statement  is  that 
the  smegma  bacilli  can  be  distinguished  from  the  tuljcrcle  bacillus  by 
less  resistance  to  decolorizing  agents,  particularly  to  nitric  acid,  hydro- 
chloric acid,  and  alcohol,  also  to  counter-stains;  and  tliis  often  holds 
true.  Nevertheless,  smegma  l)acilli  are  sometimes  encoinitered  ^vhich 
are  as  resistant  to  these  decolorizers  as  are  tubercle  bacilli.  Especial 
attention  should  be  given  to  the  morphological  appearances,  as  the  size 
and  shape  of  the  bacilli  often  suflice  for  the  distinction,  although  there 
is  considerable  diversity  as  regards  this  feature  bet\\een  the  different 
smegma  bacilli  which  resist  decolorizntion.  Although  smegma  bacilli 
may  be  present  with  pathogenic  bacteria  in  lesions  around  the  genitals 
and  anus,  they  are  not  known  to  possess  pathogenic  capacity. 

Mau}^  bacteria  are  attached  to  the  hairs  of  the  body,  and  particles 
containing  bacteria  may  readily  be  detached  from  the  hair.  luibb  has 
studied  the  bacteria  which  fall  off  from  the  hair  of  the  head  by  move- 
ment or  by  combing  tiie  hair.  They  are  identical  with  those  found  on 
the  skin,  as  might  be  expected.  Haegler  has  cultivated  pyogenic  staph- 
ylococci from  the  hair  of  surgeons,  and  calls  attention  to  the  possi- 
bility of  such  cocci  falling  from  the  hair  into  a  wound  or  upon  objects 
coming  into  contact  with  the  wound  during  an  operation.  AVriglit  has 
found  the  diphtheria  bacillus  on  tlie  hair  of  nui'ses  in  attendance  on 
cases  of  diphtheria. 

The  cerumen  is  rich  in  bacteria.  Kohrer  -  isolated  sixteen  sjiecies  of 
micro-organisms  from  the  cerumen  of  fifty  cases,  but  he  has  not  attempted 

'  Buday,  Pester  Med.-chir.  Pressr,  1894,  No.  19. 
^  Eohrer,  Archivf.  Ohrenheilk.,  Bd.  xxix. 


BACTERIA    OF  EXPOSED  MUCOUS  SURFACES.  25.5 

to  identify  any  of  these  with  prcvious;ly-knowii  Imcteria,  and  his  .state- 
ments as  U)  tht'  existence  of  patliogenic  bacteria  in  the  cerumen  are  not 
based  upon  conclusive  observations. 

Bacteria  of  Exposed  Mucous  Surfaces. 

The  wav  is  open  for  the  access  of  micro-organisms  to  mucous  mem- 
bi'anes  wliich  cover  parts  wliicii  communicate  with  the  outer  world 
through  the  external  oritices  of  the  body.  So  far  as  temperature,  moist- 
ure, and  the  presence  of  nutritive  pabulum  are  concerned,  the  conditions 
are  manifestly  more  favorable  for  the  growth  of  bacteria  upon  mucous 
surfaces  than  upon  the  dry  skin.  These  relatively  favorable  conditions 
for  the  develoiMiient  of  micro-organisms  upon  mucous  membranes  are, 
however,  counteracted  in  large  measure  by  various  mechanical  and  chem- 
ical influences  which  prevent  the  prolonged  survival  of  most  of  the  bac- 
teria which  may  enter  through  the  external  orifices  of  the  body.  There 
are,  however,  many  bacteria  which  may  multiply,  or  persist  for  a  long 
time  or  indefinitely,  upon  certain  mucous  membranes  in  health,  partic- 
ularly those  of  the  alimentary  canal  and  of  the  upper  respiratory  tract, 
and  there  are  some  bacterial  species  which  find  their  natural  home  here. 
Some  pathogenic  bacteria  may  live  upon  certain  mucous  membranes 
without  doing  harm. 

The  study  of  the  bacterial  flora  of  exposed  mucous  membranes  in 
health  and  in  disease  has  brought  to  light  many  points  of  surgical 
interest. 

CoN.JUNCTiVA. — The  bacteriology  of  the  conjimctiva  has  been  inves- 
tigated bv  manv  ophthalmologists,  of  whom  may  be  especially  mentioned 
Fick,  Weeks,  Leber,  Felser,  van  Genderen  Stort,  Gombert,  Bernheim, 
Hildebrandt,  Franke,  Marthen,  and  Bach.^ 

When  one  considers  the  cx])osed  situation  of  the  conjunctiva,  it  is 
surprising  to  find  how  small  is  tiie  number  of  bacteria  usually  pre.sent  in 
the  conjunctix'al  Sac.  Fick  found,  by  microscopical  examination  of  fifty 
healtiiy  coujunctivte,  bacteria  in  only  eighteen,  aithougii  in  another  series 
in  which  forty-nine  healthy  eyes  of  paupers  were  examined  bacteria  were 
missed  in  only  six.  A  negative  microscopical  examination,  however, 
indicates  only  that  the  number  of  bacteria  is  small,  as  then  their  presence 
may  readily  be  overlooked  without  the  aid  of  cultures.  As  a  matter  of 
fact,  cultures  from  the  healthy  conjunctival  sac  usually  furnish  colonics 
of  bacteria.  Their  number  may  be  considerable,  l)ut  it  oftt'n  ha]ipens 
that  not  more  than  three  or  four  colonies  develop  from  a  loopful  of  fluid 
from  the  conjunctiva,  and  it  is  not  very  unconmion  for  culture  media 
inoculated  in  this  way  to  remain  sterile.  It  is  to  be  assumed  that  the 
conjunctival  sac  ordinarily  contains  bacteria.  The  secretion  within  the 
lachrymal  glands  is  sterile. 

Bach  describes  twenty-six  species  of  bacteria  isolated  in  pure  culture 
from  the  healthy  or  diseased  conjunctiva.  Of  these,  ten  are  liipiefying 
cocci,  nine  non-liquefying  cocci,  five  liquefying  bacilli,  one  non-liquefying 
bacillus,  and  one  cladothrix.  Ten  of  the  twenty-six  bacteria  were  found 
to  be  more  or  less  pathogenic  when  inoculated  into  the  rabbit's  cornea. 

'  L.  Bacli,  "Ueb.  d.  Keimgehalt  ties  Biiidchautsackes,"  Archiv  f.  Ophthalmoloyie,  lid. 
xl.  p.  130.     This  article  contains  the  references  to  the  other  articles  cited  in  the  text. 


256       GENERAL  BACTERIOLOGY  OF  SURGICAL  INFECTIONS. 

Pink  yeast  and  mould  fungi  liave  also  been  cultivated  fnmi  the  con- 
junctiva. 

Bach  considers  that  of  these  various  bacteria  ovAy  the  staphylococcus 
pyogenes  aureus  and  albas  and  tiie  strejitococeus  jn'ugenes  are  demon- 
strated to  be  pathogenie  for  man,  although  the  possibility  that  others  in 
the  list  maybe  pathogenic  for  man  must  be  admitted.  In  a  few  instances 
the  staphylococcus  pyogenes  aureus,  and  in  more  the  albus,  have  been 
cultivated  from  the  healthy  conjunctiva.  Cultures  of  the  staphylococcus 
j)vogenes  aureus  lune  l)een  introduced  into  the  healthy  conjunctival  sac 
of  man  and  animals  withdut  causing  inflammation. 

Inasmuch  as  many  micro-organisms  must  enter  the  conjunctival  sac 
from  the  air,  the  edges  of  the  eyelids,  and  from  contact  with  the  fingers 
and  other  objects,  and  as  relatively  few  bacteria  are  found  ordinarily  in 
cultures  from  this  jiart,  it  is  evident  that  there  must  be  some  very  efficient 
mechanism  which  rids  the  conjunctiva  of  most  of  the  bacteria  which  enter. 
There  are  two  principal  agencies  by  which  this  may  be  accomplished — 
namely,  mechanical  removal  through  the  naso-lachrymal  duct,  and  the 
germicidal  action  of  the  lachrymal  and  conjunctival  secretions.  Some 
investigators  have  attached  the  greater  importance  to  the  former,  others 
to  the  latter,  of  these  agencies.  Experiments  have  shown  that  each  may 
be  operative,  but  the  mechanical  removal  has  been  shown  to  be  especially 
efficient  and  prompt  in  its  action. 

Van  Genderen  Stort  has  made  experiments  upon  raliliits,  and  Bach 
upon  man,  by  dropping  pure  liquid  cultures  of  easily-identified  bacteria, 
such  as  the  Kielwater  bacillus,  the  bacillus  coli  communis,  the  staphylo- 
coccus aureus,  into  the  conjunctival  sac,  and  then  determining  by  cultures 
the  length  of  time  during  which  they  can  be  demonstrated.  Van  Gen- 
deren Stort  found  after  fifteen  minutes  the  inoculated  bacteria  reduced 
to  a  small  number,  and  at  the  end  of  an  hour  they  had  nearly  or  entirely 
disappeai'ed  from  the  conjmictival  sac.  Cultures  from  the  nose  showed 
that  they  had  been  carried  down  the  naso-lachrymal  duct,  and  that  after 
five  minutes  they  were  abundant  in  the  cultures  from  the  nasal  cavity. 
Identical  results  were  obtained  by  Bach  in  his  experiments  on  human 
beings.  In  the  experiment  of  Bach  with  the  staphylococcus  aureus, 
however,  which  was  introduced  in  such  munber  that  the  innnediate 
plates  from  the  conjunctiva  contained  countless  colonies,  there  were  still 
seventy-four  colonies  in  the  plates  made  after  twenty-four  hours. 

The  same  experiments' were  made  after  ligation  of  the  naso-lachrymal 
duct.  Under  these  circumstances  the  inoculated  bacteria  also  disappeared 
from  the  conjunctival  sac,  but  more  slowly  than  when  the  duct  was  open. 
Still,  after  an  hour  most  of  the  bacteria  had  been  removed.  It  was  found 
that  they  had  been  carried  away  by  the  lachrymal  secretion  which  flowed 
over  the  eyelids.  If  the  eyelids  were  closed  by  a  bandage,  the  bacteria, 
with  open  nasal  duct,  rapidly  passed  down  into  the  nose,  and  they  did 
not  appear  to  pass  out  between  the  closed  eyelids.  When,  however,  the 
duct  was  closed,  they  appeared  aljiindantly  in  the  bandage. 

Bernheim  has  demonstrated  that  the  tears  possess  considerable  bacteri- 
cidal jjower  over  certain  species  of  bacteria,  and  his  results  have  been  in 
part  confirmed  by  the  experiments  of  IMarthen,  Bach,  and  others.  The 
staphylococcus  pyogenes  aureus  is  killed  in  moderate  number,  and  the 
typhoid  bacillus  in   larger  number,  by  the   lachiymal   secretion.     We 


BACTERIA   OF  EXPOSED  MUCOUS  SURFACES.  ,257 

must  therefore  assign  im|)(irt;uu'e  to  this  chemical  action,  as  well  as  to 
the  mechanical  removal,  in  ridding  the  conjunctiva  of  invading  bacteria. 
Neither  of  these  agencies  suffices  to  remove  all  of  the  bacteria.  Some 
bacteria  grow  reatlily  in  the  fluid  of  the  conjunctiva.  As  has  already 
been  mentioned,  the  coujuctiva  nearly  always  contains  some  bacteria. 
The  orifices  of  tlie  Mciliomian  glands,  the  cilia,  and  tlie  edges  of  the  eye- 
lids usually  contain  many  bacteria,  and  tliese  of  course  may  readily  enter 
the  conjunctival  sac. 

Bach  was  unable  to  demonstrate  that  liacteria  introduced  into  the 
nasal  cavity  ever  make  their  way  up  the  nasal  duct  to  the  eye. 

It  is  difficult  to  obtain  complete  disinfection  of  the  conjunctival  sac. 
The  number  of  bacteria  may  be  greatly  reduced,  either  by  the  ai)plieation 
of  antiseptics  or  bv  simple  mechanical  cleansing,  ct)mbined  with  irriga- 
tion by  an  iuditferent  fluid,  sucli  as  sterilized  salt-solution.  Bach  obtained 
the  best  results  by  the  latter  procedure,  by  which  in  sixteen  outof  ibrty- 
two  cases  he  rendered  the  conjunctiva  sterile. 

The  importance  of  familiarity  with  the  saprophytes  to  be  found  on 
exposed  mucous  membranes  is  illustrated  by  the  history  of  the  so-called 
xerosis  bacillus.  Tliis  bacillus  was  discovered  by  Neisser  in  1882  in 
xerosis  of  the  conjunctiva,  and  was  I'cgarded  by  liim  as  the  cause  of  this 
disease.  This  C(jnclusiou  was  adopted  by  several  subsequent  investigators, 
who  found  this  bacillus  constantly  present  in  xerophthalmia.  This  same 
bacillus  has,  however,  been  demonstrated  by  Schreiber,  working  under 
Neissor's  direction,  in  various  other  affections  of  the  eye,  and  also, 
although  in  small  numbei',  in  the  normal  conjunctival  sac.  Neisser  has 
therefore  given  his  assent  to  the  conclusi()n  expi'essed  by  Schreiber:' 
"  Tlie  so-called  xerosis  bacilli  are  to  be  regarded  as  saprophytes  whidi 
ai'e  often  present  in  the  conjunctiva  and  its  secretion,  both  in  diseased 
and  healthy  eyes,  and  they  play  no  special  r6le  either  in  xerosis  or  in 
other  diseases  of  the  eye." 

The  xerosis  bacillus  belongs  to  an  interesting  group  of  bacteria  which 
are  characterized  l)y  ri'markal)lc  irregularities  in  size  and  shape — so-called 
involution  fcjrms — and  l)y  irregularities  in  staining,  especially  by  the 
presence  of  deeply-staining  isolated  granules.  It  is  not  positively  proven 
to  form  spores,  although  some  of  the  isolated  granules  are  interpreted 
as  such  by  Ernst  and  by  Xeisser.  To  this  same  group  belong  the 
diphtheria  bacillus  of  Lijffler  and  the  so-called  pseudo-diphtheria 
bacilli. 

Mouth  and  Pharynx.^ — All  of  tlie  micro-organisms  which  may 
be  present  in  the  air,  food,  and  ingested  fluids  may  appear  temj)orarily  in 
the  mouth.  The  number  of  bacteria  which  have  been  cultivated  ft-om 
the  human  mouth  is  very  large.  Miller  has  isolated  over  one  hundred 
species.  Freund  has'  cultivated  eighteen  ditterent  chromogenic  micro- 
organisms fnim   the  mouth. 

It  is  important  to  distinguish  between  the  countless  bacteria  which 
may  appear  as  transient  visitors  in  the  moutli  and  those  which  find  their 
permanent  home  there.     \  remarkable  peculiarity  of  the  constant  inhabit- 

'  Schreiber,  Forlschrilte  chr  Medichi,  1888,  p.  656. 

■  Miller,  Die  Mikro-orijanismen  der  MundhShle,  Leipzig,  1889;  David,  Les  Slicrobes  de 
la  linuche,  Paris,  1890.     These  valuable  works  present  the  most  important  results  hitherto 
obtained  by  the  investigators  of  the  micro-organisms  of  the  mouth. 
Vol.  I— 17 


258       GENERAL   BACTERIOLOGY  OF  SURGICAL  INFECTIONS. 

ants  of  the  saliva  is  that  most  of  tlicm  will  not  t;ru\v  in  unr  artiticial 
cnlturc  nu'dia.  This  produces  often  a  strikinji'  discrepaney  between  the 
results  of  niicroscopieal  examination  of  tiie  huceal  secretions  and  those 
ol)tain((l  by  cultures.  Cover-slip  specimens  may  show  an  enormous 
number  of  bacteria,  when  cultures  made  from  the  same  material  may 
show  very  few  or  even  no  colonies. 

Miller  enumerates  the  following  as  the  constant  buccal  bacteria : 
leptothrix  buccalin  innominata,  bacillm  buccalw  ma.vimus,  Upfofhrix  Imc- 
calis  'maxima,  iodococcu.s  rar/inatuK,  xpirUIuut  sjiufir/cmnii,  xjiirochaic 
(Jcnlhmi.  Xone  of  these  have  been  artificially  cultivated.  Uacillus  buc- 
calis  maximus  and  iodococcus  vaginatus  are  stained  violet  by  iodine 
solution.  These  bacteria  are  often  present,  with  others,  in  carious  teeth, 
in  abscesses  communicating  with  the  mouth  and  pharynx,  and  in  exudates 
on  the  nuicous  membranes  of  these  parts,  but  they  have  not  been  proven 
to  be  j)atliogenie. 

The  frequent  presence  of  j)athogenic  bacteria  in  the  healthy  mouth  is 
of  great  practical  importance.  The  following  patliogenic  bacteria  have 
been  found  repeatedly  in  this  situation  :  micvococcMS  lanceolatm,  strepto- 
coccus pyogenes,  staphy/oeorcus  pyogenes  aureus  and  albus,  micrococcus 
tctrageuus,  bacillus  pneituionia:  of  Friedliinder,  bacillus  crassus  sputigenus 
of  Kreibohm,  bacillus  coli  comnmnis.  Biondi,  Miller,  Kreibohm,  Galij)pe, 
and  others  have  found  in  the  mouth  additional  pathogenic  bacteria  in 
isolated  cases,  mostly,  however,  with  some  morbid  condition. 

The  micrococcus  lanceolatus  was  discovered  by  Sternberg  in  his  saliva 
in  1880.  Many  names  have  been  given  to  this  bacterium,  the  more 
common  svnonvms  being  di]doeoeeus  pneumoni;e,  pneumococcus  of 
Fraenkel  and  M'eichselbaum,  diploeoccns  lanceolatus,  micrococcus  of 
sputum  septiciemia,  and  micrococcus  pncumoni;e  erujiosa'  (Sternberg). 
This  micro-organism  was  found  by  Netter  in  a  virulent  condition  in  15  to  20 
per  cent.,  of  the  healthy  persons  whom  he  examined.  It  varies  markedly 
in  virulence,  and  it  is  probably  present  in  a  non-virulent  condition  in 
many  eases.  Indeed,  Kruse  and  Pansini  believe  that  the  micrococcus 
lanceolatus  is  a  regular  inhabitant  of  the  human  mouth,  although  it  is 
present  in  a  virulent  state  in  only  alxint  one  out  of  five  or  six  persons. 
As  the  lanceolate  coccus,  especially  when  its  virulence  is  weak  or  absent, 
may  grow  in  chains  and  present  cultural  characters  of  the  streptococcus 
pyogenes,  it  is  often  difficult,  if  not  impossible,  to  distinguish  between 
these  bacteria. 

The  chief  interest  attacliing  to  the  frequent  presence  of  the  micro- 
coccus lanceolatus  in  the  healtjiy  mouth  is  that  this  bacterium  is  the 
cause  of  lobar  pneumonia  and  of  many  cases  of  broncho-pneumonia. 
It  may  also  be  concerned  in  local  inflammations  of  the  throat,  and  as  a 
primary  or  secondary  invader  may  cause  serositis  and  localized  inflam- 
mations in  various  parts  of  the  body  ;  but  the  streptococcus  pyogenes  is 
a  more  common  cause  of  these  lesions. 

Various  virulent  and  non-virulent  streptococci  have  been  foiuid  in 
the  mouth,  both  shoi't-ehained  streptococci  and  long-chained  forms,  corre- 
sponding to  the  two  varieties,  streptococcus  brevis  and  strejitococcus 
longus.  The  distinctions  upon  which  these  varieties  were  established  by 
Von  Lingelsheim  are  often  inconstant,  and  do  not  serve  for  a  slmrj) 
differentiation.     The  chief  interest  belongs  to  the  presence  in  the  mouth 


BACTERIA    OF  EXPOSED  MUCOUS  SURFACES.  259 

and  pliaryux  of  the  streptococcus  ])yogcnos.  Netter  found  the  strepto- 
coccus p\ogenes  in  seven  out  of  one  hundred  and  twenty-seven  healtliy 
mouths  examined;  that  is,  in  5.0  per  cent,  of  the  cases.  Dornberger 
found  streptococci  iu  the  mouths  of  iiealtiiy  cliildren  in  45  per  cent,  of 
the  ninety-four  cases  examined.  Widal  and  Besanjon  found  streptococci 
constantly  and  in  large  number  in  the  mouths  of  twenty  healthy  persons, 
and  still  more  abundantly  in  the  mouth  and  pharynx  of  forty-nine 
persons  aiibcted  with  varii)us  diseases. 

It  often  requires  a  painstaking  examination  to  detect  this  strcptn- 
coccus.  The  colonies  are  minute  and  pale  gray,  and  iu  a  plate  crowded 
with  other  more  striking  colonies  the  former  may  escape  recognition 
unless  es])ecial  attention  is  given  to  them.  If  the  secretions  of  the 
hcalthv  mouth  and  throat  be  carefully  examined  both  by  cover-slip 
preparations  and  by  agar  plate-cultures,  streptococci  will  be  found  with 
great  frei[uency,  if  not  reguhirly,  although,  as  already  mentioned,  it  is 
by  no  means  easy  to  distinguish  some  of  the  streptococci  from  chain 
forms  of  the  micrococcus  lanceolatus. 

The  number  of  streptococci  is  increased  and  their  detection  is  much 
easier  in  most  inflammatory  conditions  of  the  tonsils  and  pharynx. 
They  are  commonly  associated  with  the  di]ihtlieria  bacillus  in  dij)litlie- 
ria,  and  they  are  capable  of  causing  all  grades  of  tonsillitis  and  pharyn- 
gitis, from  slight  erythematous  forms  to  pseudo-membranous  antl  necrotic 
inflannnations. 

Streptococci  cultivated  from  the  healthy  mouth  usually  have  little  or 
no  virulence  as  tested  upon  animals,  and  the  same  is  often  true  of  strcji- 
tococci  cultivated  from  the  throat  in  various  infections,  local  and  gen- 
eral, although  in  these  cases  they  are  more  likely  to  be  pathogenic  for 
animals. 

The  stre])tococcus  pyogenes  is  a  common  and  dangerous  invader  of 
the  deeper  air-passages  and  lungs  and  of  the  internal  parts  of  the  body. 
The  portal  of  entry  is  often  the  tonsils  and  throat,  and  predisposing 
causes  are  inflammations  and  other  lesions  of  these  parts,  particularly 
when  combined  with  other  infectious  diseases  and  constitutional  disturli- 
ances.  Under  conditions  little  understood  the  mouth-streptococci  may 
acquire  enhanced  virulence. 

The  influence  of  predisposing  causes  as  a  factor  in  the  etiology  of 
infections  is  well  exemplified  by  the  fact  that  healthy  mucous  membranes 
harl)or  very  frequently  sucli  pathogenic  germs  as  the  micrococcus  lanceo- 
latus and  the  streptococcus  j)yog<'nes.  These  bactei'ia  often,  moreover, 
cause  no  serious  disturbance  in  the  repair  of  wounds  and  injuries  involv- 
ing the  mouth  and  naso-pharynx,  although  they  must  gain  access  to 
such  wounds.  Theyare,  however,  a  standing  menace  in  surgical  ope- 
rations involving  these  parts,  a'i.d  they  may  seriously  interfere  with  the 
healing  of  such  wounds,  or  may  under  these  circumstances  set  up  pneu- 
monia and  general  infection. 

Staphylococci  are  found  often  in  the  healthy  mouth  and  the  throat, 
but  the  genuine  pyogenic  staphylococci  do  not  appear  to  be  present  Mitli 
great  fre(juency.  Vignal,  Netter,  and  Miller  met  the  staphylococcus 
pyogenes,  aureus  only  in  a  com])aratively  small  number  of  cases  in  their 
bacteriological  examinations  of  the  healthy  mouth.  It  is  found  more 
frcfpiently  in  various  inflanunations  of  the   nuicous  membranes  of  this 


260       GENERAL  BACTEIilOLOGY  OF  SURGICAL  INFECTIONS. 

region,  but  it  plays  no  such  importnut  role  in  these  as  does  the  strepto- 
coccus pyogenes. 

Wliite  liquefying  cocci,  often  described  as  the  staphylococcus  pyog- 
enes albus,  are  l'(nind  oftener  than  the  staphylococcus  aureus  in  the 
mouth  and  throat.  Some  of  these  have  been  shown  to  possess  j)yogenic 
power,  and  may  be  accepted  as  the  staphylococcus  pyogenes  albus,  but 
others  are  devoid  of  such  power. 

According  to  the  statements  of  Biondi,  Miller,  and  others,  the  micro- 
coccus tctragenus,  which  was  discovered  l)y  Koch  and  Gatfky  in  a 
phthisical  cavity,  is  often  present  in  the  mouth.  In  a  considerable 
number  of  cases  examined  by  the  writer  it  was  absent.  The  frequency 
with  which  certain  bacteria  are  present  in  the  mouth  probably  varies 
considerably  in  different  regions  and  according  to  the  class  of  cases 
selected  for  examination.  There  are  various  species  of  tetragenous  cocci. 
The  jiathogenic  form  of  Koch  and  GafFky  is  designated  by  Boutron  as 
micrococcus  tctragenus  septicus.  This  organism  is  present  more  fre- 
quently in  abscesses  in  the  neighliorhood  of  the  mouth  and  throat,  par- 
ticularly those  connected  with  carious  teeth,  than  in  abscesses  in  other 
parts  of  the  body,  although  even  in  the  former  it  is  rarely  present. 

The  virulent  di])htheria  liacillus  was  found  by  Park  and  Beebe '  in 
the  healthy  throats  of  eight  out  of  three  iumdred  and  thirty  ])ersons  in 
New  York  who  gave  no  history  of  direct  contact  witli  cases  of  <liphthe- 
ria.  Only  two  of  these  eight  persons  afterward  developed  diphtlieria. 
They  found  non-virulent,  but  otherwise  characteristic,  diphtheria  bacilli 
in  twenty-four  throats  of  the  same  gi'oup  of  persons,  and  pseudo-diph- 
theria Ijacilli    in  twenty-seven. 

The  pseudo-di])litheria  bacillus  which  is  occasionally  found  in  the 
throat  is  devoid  of  virulence,  and  presents  certain  cultural  peculiarities 
distinguisiiing  it  from  the  genuine  di))htheria  bacillus.  It  is  not  known 
to  be  pathogenic.  There  is  much  confusion  in  the  use  of  the  term 
"pseudo-diphtheria  bacillus,"  and  some  writers  have  described  under 
this  name  the  genuine  diphtheria  bacillus  devoid  of  virulence.  There  is 
]irobal)ly  more  than  one  bacterial  species  which  may  be  called  pseudo- 
diphtiicrial  l)acillus. 

The  mouth  and  adjacent  parts  are  the  most  frequent  portals  of  entry 
of  the  bacterium  of  actinomycosis.  This  organism  is  likely  to  lodge  near 
carious  teeth. 

Although  the  mouth  and  throat  offer  more  favorable  conditions  for 
the  ])rolonged  existence  of  many  micro-organisms  than  do  other  exposed 
mucous  nicmljrane,  nevertheless  of  the  vast  hordes  of  micro-organisms 
whicli  nmst  gain  access  to  the  mouth  only  a  small  number  actually  per- 
sist there.  The  conditions  are  evidently  unfavorable  for  the  survival  of 
the  majority  of  bacterial  species  in  this  situation.  Those  which  are  unable 
to  gain  a  foothold  must  sooner  or  later  pass  down  into  the  stomach  or 
intestine  or  out  through  the  mouth  and  nose  or  perish  within  the  body. 

The  secretions  in  the  mouth  and  throat,  like  most  of  the  fluids  of  the 
body,  possess  some  degree  of  germicidal  power.  Sanarelli"  found  that 
the  saliva  is  capable  of  killing  in  a  short  time  a  moderate  number  of 

'  Welch,  "  BacterioloKical  Investigations  of  Diplitheria  in  the  United  States,"  Am. 
Jniim.  (jf  the  Med.  Sciences,  Oct.,  1894. 

2  Sanarelli,  Centmlbl.  f.  Bakle,:,  1891,  Bd.  x. 


BACTERIA    OF  EXPOSED  MUCOUS  SURFACES.  261 

several  pathogenic  bacterial  species.  This  was  found  to  be  the  case  with 
the  staphylococcus  aureus,  the  streptococcus  pyogenes,  the  micrococcus 
tetragenus,  tlie  typhoid  bacillus,  and  the  cholera  spirillum.  Tiie  diph- 
tlieria  bacilhis,  iiowever,  survived  for  twenty-eiglit  to  forty  days,  and  the 
micrococcus  lauceolatus  grew  well  in  sidiva,  although  with  rajiid  loss  of 
virulence. 

E.  Grawitz  and  Stcffen'  liave  confirmed  this  observation  of  Sanarclli 
as  regards  the  pneumococcus,  and  have  found  that  the  virulence  of  this 
organism  may  be  restored  by  cultivating  it  upon  pneumonic  sputum  pre- 
pared as  an  artificial  culture  medium.  TJiey  interpret  this  as  indicating 
that  the  virulence  of  the  jineumoeoccus  may  be  enhanced  by  certain 
chemical  changes  in  the  comjjosition  of  the  sputum. 

There  is  reason  to  believe  that  the  virulence  of  pathogenic  bacteria  in 
the  mouth,  notalily  of  the  micrococcus  lanceolatus  and  the  streptococcus 
pyogenes,  may  fluctuate,  both  in  the  direction  of  attenuation  and  of 
exaltation,  but  we  are  not  acquainted  with  the  conditions  wliich  control 
these  changes. 

The  salivary  glands  and  ducts  are  free  from  bacteria,  except  near  the 
orifice  of  the  ducts. 

Respiratory  Passages  and  Middle  Ear. — In  normal  respiration 
the  bacteria  contained  in  the  inspired  air  must  enter  the  nasal  cavities. 
The  anatomical  arrangement  of  the  nasal  passages  renders  these  an  im- 
portant filtering  apparatus  fur  the  protection  of  the  deeper  air-passages. 
It  has  been  shown  by  experiments  of  Wright  that  with  a  respiration  of 
one  litre  of  air  per  minute  from  three-fourths  to  four-fifths  of  the 
bacteria  of  the  inspired  air  are  retained  in  the  nasal  cavities  and  their 
adnexa. 

It  has  already  been  mentioned  that  most  of  the  bacteria  which  enter 
the  conjunctival  sac  are  carried  into  the  nose  through  the  nasal  duct. 
We  should  therefore  expect  that  the  nasal  cavities  would  contain  abun- 
dant niicro-iirganisms. 

The  bacteria  of  the  healthy  nose  have  been  studied  by  E.  Fraenkel, 
Loewenberg,  Hajek,  von  Besser,  Wright,  Paulsen,  Weibel,  Deletti,  and 
others,  witli  much  divergence  in  their  results.  Some  have  found  few, 
others  many,  bacteria  in  the  nose ;  some  have  met  frequently  jMthogenic 
bacteria,  others  rarely  or  not  at  all. 

Von  Besser-  describes  twelve  non-pathogenic  species  isolat(Ml  from 
the  noses  of  thirty  persons  at  work  in  the  laboratory.  In  the  same  group 
of  cases  he  found  in  the  nose  the  micrococcus  lanceolatus  six  times,  the 
streptococcus  pyogenes  five  times,  the  staphylococcus  pyogenes  aureus 
seven  times.  In  the  nasal  cavities  of  twenty-eight  convalescent  hosjiital 
patients  he  found  the  micrococcus  lanceolatus  four  times,  and  the  strc])- 
tococcus  pyogenes,  the  staphylococcus  pyogenes  aureus,  and  the  bacillus 
of  Friedliinder  each  once ;  in  twenty-three  soldiers  and  servants,  the 
micrococcus  lanceolatus  four  times,  the  staphylococcus  pyogenes  aureus 
six  times,  the  streptococcus  pyogenes  once,  and  the  Friedliinder  bacillus 
once. 

Wright^  isolated  from  the  nasal  secretion  of  ten  healthy  persons  the 

'  Grawitz  and  Stcffen,  Berliner  kliii.  Wochenschr,,  1894,  No.  18. 

^  Von  Besser,  Zirrjier.f  Beitriiqe,  Bd.  vi. 

'  Wright,  New  York  Med.  Journ.,  July  27,  1889. 


202       OEXERAL  BACTERIULOGY   OF  SUIiOICAL  lyFECTIOyS. 

sta|)hyl()co('('ns  jnoticnos  nlhiis  six  times,  the  aureus  and  eitreus  three 
times,  tiie  baeilhis  lactis  aenmeiies  ouee,  and  tlie  microeoceus  tetragenus 
once. 

Paulsen'  uiade  sixty-tour  cultures  from  the  iiealthy  noses  of  twenty- 
seven  persons.  Eleven  of  these  were  sterile,  nineteen  gave  ten  colonies 
or  less,  sixteen  gave  u])  to  one  hundred  colonics,  twelve  several  hundred 
colonies,  and  six  furuisiicd  countless  colonies.  Cocci  were  found  much 
oftener  than  bacilli.  Only  once  did  he  find  the  streptococcus  pyogenes. 
Pathogenic  bacteria  were  not  observed  in  any  other  of  the  normal  cases. 
Upon  eover-sliji  preparations  lie  noted  spirilla,  and  Weibel  has  cultivated 
a  comma  bacillus  from  the  nose. 

Special  interest  attaches  to  the  presence  of  eapsulated  bacilli  in  the 
nose,  as  these  are  found  with  great  frequency,  if  not  constantly,  in 
ozfeua.  The  oziena  l>acilhis  of  Abel"  resembles  closely  the  Pricdliinder 
liacillus,  l)ut  is  believed  by  him  not  to  be  identical  with  it.  AVhcther  or 
not  this  l)acillus  is  ever  found  in  the  healthy  nose  is  not  established.  The 
Friedliinder  bacillus  and  the  lanceolate  coccus  have  repeatedly  been 
found  in  the  nose,  especially  in  inflammatory  conditions.  The  rhino- 
scleroma  bacillus  is  a  eapsulated  bacillus  much  liki'  the  Friedliinder  liacil- 
lus, but  differing  from  it  l:>y  staining  -with  (ii'am's  method.  ^A'e  do  not 
at  present  possess  an  entirely  satisfactory  differentiation  of  a  grou])  of 
eapsulated  bacilli  to  which  Fricdliindcr's  l)acillus,  the  ozrena  bacillus, 
the  rhinoscleroma  bacillus,  the  eapsulated  bacillus  of  Pfeiffer,  and  some 
others  belong. 

The  diphtheria  bacillus  is  constantly  found  in  fibrinous  rhinitis. 
Various  bacteria,  especially  dijilococci,  have  been  found  in  the  secretion 
of  corvza.  When  this  secretion  is  abundantly  ]>oured  out,  it  often 
happens  that  cultures  from  several  drops  of  it  contain  very  few  colonies 
or  are  sterile. 

Straus  has  recently  made  the  imjiortant  observation  that  the  tubercle 
bacillus  is  often  present  in  the  nasal  cavities  of  healthy  pei'sons  who 
spend  much  of  their  time  in  proximity  to  tuberculous  patients.  He 
examined  for  tubercle  bacilli  the  contents  of  the  nasal  cavities  of  those 
engaged  about  hospital  wards  containing  consumjiti\cs.  Twenty-nine 
such  examinations  were  made  by  the  inoculation  of  guinea-pigs.  In 
nine  cases  the  guinea-pig  developed  tuberculosis.  Of  these  nine  persons, 
six  were  healthy  attendants  occupied  in  such  work  as  sweejiing  the  floor 
and  shaking  bed-linen,  one  was  a  patient  with  a  chronic  nou-tul)erculous 
ailment,  and  two  were  medical  students  who  spent  several  hours  daily  in 
the  hospital.  None  of  these  individuals  presented  the  slightest  evidence 
of  tuberculosis.  These  observations  are  even  more  significant  than 
those  of  Cornet  as  to  the  abundance  and  wide  distribution  of  tubercle 
bacilli  in  the  neighborhood  of  consumptives. 

Wurtz  and  Lermoyez  have  found  that  the  nasal  mucus  possesses  con- 
siderable bactericidal  capacity. 

Von  Besser  found  bacteria  abundantly  in  the  larynx  and  bronchi  of 
human  corpses,  but  he  demonstrated  that  after  death  the  fluids  from  the 
mouth  and  naso-pharynx  may  readily  penetrate  even  into  the  smaller 
bronchi,  and  moreover  in  his  cases  the  lungs  and  air-passages  Mere  dis- 

'  Paulsen,  Cenlrolhl.  f.  Bitkter.,  Bd.  viii.  p.  344. 
'^  Abel,  ibid.,  Bd.  xiii.  )i.  161. 


BACTERIA    OF  EXPOSED  MUCOUS  SURFACES.  2G3 

eased  ;  so  tliat  lie  attaches  no  importance  to  his  observations  as  hearing 
upon  the  question  of  tlie  presence  of  bacteria  in  tlicse  parts  in  iiealtli. 

Hihli'!)ran(lt  '  found  tiiat  culture  media  inocuhited  witli  l)its  of  the 
huig-  and  of  traelieal  mucus  from  recently-killed  rabl)its  usually  remained 
sterile,  and  he  concludes  that  practically  all  bacteria  which  enter  with 
the  air  are  retained  in  the  upper  air-passages  and  do  not  penetrate  below 
the  larynx.  This  protection,  however,  has  its  limits,  as  when  the  inspired 
air  was  loaded  with  fungus-spores  these  could  l)c  demonstrated  after 
half  an  hour  in  the  lungs.  That  foreign  particles  in  the  air  may  be 
conveyed  into  the  lungs  is  evidenced  by  the  coal  particles  regularly 
found  in  the  lungs. 

Wargunin,  in  opposition  to  Hildebrandt,  isolated  nine  different  kinds 
of  bacteria  from  the  trachea,  bronchi,  and  lungs  of  recently-killed 
healthy  animals. 

The  observations  of  the  writer  are  in  harmony  with  Hildebrandt's 
results  as  to  the  usual  absence  of  Ijacteria,  at  least  in  sntticient  number 
to  be  demonstrable  by  ordinary  culture  metliods,  in  the  bronchi  and 
lungs  of  healthy  animals. 

At  autopsies  on  human  beings  bacteria,  including  the  micrococcus 
lanceolatus  and  the  streptococcus  pyogenes,  may  be  found  in  tlic  lungs 
withiiut  notie(>able  lesion  of  this  organ. 

The  action  of  the  ciliated  epitlielium  and  coughing  would  tend  to 
drive  out  bacteria  which  may  have  entered  the  trachea  and  bronchi. 

The  expired  air  is  free  from  micro-organisms,  except  as  these  may  be 
mechanically  detached,  as  in  sneezing  or  coughing. 

^\'e  are  not  informed  as  to  the  frequency  with  which  bacteria  are 
])resent  in  tiie  healthy  tymjianic  cavity.  That  bacteria  may  pass  up  the 
p]ustacliian  tube  into  the  middle  ear  is  shown  by  the  presence  in  otitis 
media  of  various  micro-organisms  often  finuid  in  the  mouth  and  naso- 
])harynx,  notably  the  micrococcus  lanceolatus,  the  streptococcus  jiyogenes, 
the  Friedliinder  bacillus,  and  the  pyogenic  staphylococci.  There  are  of 
course  other  paths  by  which  micro-organisms  may  be  carried  into  the 
middle  ear,  as  the  lymphatic  and  l)lood-currents,  and  in  meningitis  from 
the  cranial  cavity. 

Netter  found  constantly  in  the  middle  ear  of  new-born  infants,  at  au- 
topsy, bacteria,  and  among  these  were  pathogenic  forms  to  which  he  attrib- 
utes the  frequent  occurrence  of  middle-ear  inflammations  in  infants.  In 
autojisies  upon  one  hundred  and  eight  infants  less  than  one  year  old 
H.  Kossel  found  otitis  media  in  eighty-five  cases.  The  most  common 
organism  in  these  cases  was  a  delicate  bacillus,  apparently  identical  with 
Pfeifl'er's  pseudo-influenza  bacillus  (38  cases).  In  addition  were  found 
the  diplococcus  pneumonia  (10),  streptococci  (4),  thick  bacilli  (2),  staphy- 
lococci (2),  and  the  bacillus  pyocyaneus  (once).  One  case  was  tubercu- 
lous otitis.  Some  writei's  are  of  the  opinion  that  changes  often  found 
in  the  middle  ear  of  the  new-born  are  jjost-mortem  alterations. 

Stomach  and  Intestine. — The  study  of  the  micro-organisms 
present  in  the  stomach  and  intestine  presents  many  jjoints  of  physi- 
ological and  jKVthological  interest,  but  we  must  confine  our  attention 
chiefly  to  those  of  surgical  interest.  When  we  consider  the  relations  of 
intestinal  bacteria  to  various  surgical  aflections,  suc'h  as  perforative  and 

'  Hikleljrandt,  Zieyler's  Beitrdgc,  Bd.  ii. 


264        CKXERAL  BACTERIOLOGY  OF  SURGICAL  INFECTIONS. 

((tlier  forms  of  peritonitis,  apjjciidicitis,  and  even  infections  remote  from 
tlu'  intestinal  canal,  it  is  apparent  tiiat  this  sulyect  claims  the  attention 
of  the  snrgeon. 

The  main  sonrces  of  the  micro-organisms  of  the  stomach  and  intes- 
tine are  the  inu^esta  and  the  air.  From  tliese  sonrces  cc^nntlcss  bacteria 
and  ftuiii'i  of  all  kinds  arc  introduced  into  the  alimentary  canal,  l)nt,  as 
is  tnic  of  other  exposed  mucous  surfaces,  only  a  limited  number  of 
species  are  capable  of  prolonged  existence  in  this  situation. 

The  meconium  of  the  new-born  infant  is  sterile,  but  within  twenty- 
four  liours  after  birth  it  usually  contains  abundant  bacteria.  Although 
many  varieties  of  bacteria  may  be  found,  Eschcricii  has  demonstrated 
a  constant  bacterial  flora  in  the  lleccs  of  milk-fed  infants.  These  con- 
stantly-present intestinal  bacteria  are  the  bacillus  lactis  aerogenes,  pre- 
dominating in  the  small  intestine,  and  the  bacillus  coli  communis,  pre- 
dominating in  the  large  intestine.  These  bacteria  remain  throughout 
lite  as  the  obligatory  and  characteristic  intestinal  bacteria  of  man  in 
health,  and  as  tiiey  are  frequent  seccmdary  invaders  of  the  body  in 
disease,  and  may  be  concerned  in  various  surgical  and  other  diseases, 
much  practical  interest  attaches  to  them. 

The  bacterial  flora  of  the  small  intestine,  particularly  in  its  upper 
part,  is  more  varied,  as  tested  by  jilate  cultures,  than  that  of  the  large 
intestine.  In  fact,  the  comparison  of  the  results  of  microscopical  exam- 
ination and  of  cultures  from  the  stools  indicates  that  a  large  number 
of  the  bacteria  in  the  fseces  are  dead. 

As  there  is  very  little  free  oxygen  in  the  intestinal  canal,  the  con- 
ditions are  not  favorable  for  the  multiplication  of  obligatory  aerobes. 
Most  of  the  bacteria  found  in  the  intestine  are  strict  anaerobes  or  facul- 
tative anaerobes,  but  anthrax  sjiores,  which  re(juire  oxygen  for  their 
germination,  develop  into  l)acilli  in  the  intestinal  canal. 

It  is  certain  that  patliogenic  l)acteria  of  many  kinds  often  find  their 
way  into  the  intestinal  canal ;  in  fact,  there  is  ])robably  no  pathogenic 
germ  which  may  not  in  certain  individuals  and  in  certain  times  and. 
places  be  present  in  the  intestine. 

It  is  true  that  the  acid  gastric  juice  may  kill  many  of  the  micro- 
organisms which  enter  the  stomach,  but  there  are  many  which  resist  its 
action.  If  we  were  to  rely  exclusively  ujjon  the  results  of  experiments 
in  the  test-tube  on  the  germicidal  action  of  the  acid  gastric  juice,  particu- 
larly the  very  acid  juice  of  some  animals,  we  should  consider  this  action 
a  formidable  obstacle  to  the  passage  of  living  bacteria  into  the  intestine. 
But  when  we  consider  the  insusceptibility  of  many  bacteria  to  weak 
acids,  the  relatively  slight  and  varying  acidity  of  the  human  gastric  juice, 
the  absence  at  times  of  any  acid  in  the  stomach,  the  withdrawal  in  large 
measure  from  the  direct  and  concentrated  action  of  the  gastric  juice  f>f 
bacteria  contained  in  ingested  masses  of  food  and  large  volumes  of  fluid, 
and  the  I'apidity  with  which  the  gastric  contents  may  pass  into  the  duo- 
denum, we  can  understand  how  micro-organisms,  even  those  very  sus- 
ceptible to  acids,  may  find  fre(]ucnt  ojiportunity  to  enter  the  intestine. 
Only  a  fraction,  usually  not  more  than  .05  to  .1  per  cent.,  of  the  total 
acidity  of  the  stomach  is  due  to  free  hydrochloric  acid,  and  the  proteid 
hydrochlorides  possess  very  little  bactericidal  power. 

Many  organisms  can  grow  in  the  human  stomach  even  when  it  is  very 


BACTERIA   OF  EXPOSED  MUCOUS  SURFACES.  265 

jiciil,  as  has  been  shown  by  Gillespie.'  The  nunil)er  and  variety  of 
niicro-org-anisins  whieh  have  been  isolated  from  tiie  luinian  stoniacli 
by  Maefadyen,  Al)elons,  Ojipler,  (Jillespie,  and  others  are  very  great, 
but  it  wonld  serve  no  useful  purpose  to  enumerate  them  liei'e.  The 
liaeilhis  lactis  aerogenes,  tlie  baeillus  coli  eommunis,  and  the  pyogenic 
cocci  may  be  specified  as  having  been  repeatedly  found  in  the  healthy 
stomach. 

The  list  of  pathogenic  bacteria  which  have  been  found  in  the  intes- 
tinal contents  is  a  long  one.  Many  are  present  only  accidentally  and  as  a 
transient  phenomenon.  Some  are  f()und  with  such  frecpicncy  as  to  merit 
special  notice.  In  general,  the  conditions  are  not  favorable  for  exten- 
sive multiplication  of  most  pathogenic  micro-organisms  in  the  healthy 
intestine. 

Pyogenic  cocci  are  rarely  absent  from  the  intestine.  They  are  often 
present  in  such  small  number  as  to  escape  detection,  but  the  great 
frcqueni'y  with  which  these  cocci,  particularly  the  strcj)tococcus  jivogenes, 
are  found  in  the  exuilate  of  perforative  jjeritonitis,  where  they  can  rapidly 
multiply,  shows  that  they  are  common  inhabitants  of  the  intestine. 
Gessner  found  a  pathogenic  streptococcus,  probably  identical  with  the 
streptococcus  pyogenes,  in  large  numbers  in  the  duodemnn  of  six  persons 
out  of  eighteen  examined  at  autopsy. 

The  bacillus  pyocyaneus  and  the  proteus  bacilli  are  also  often  jm'sent 
in  the  intestine.  The  tetanus  bacillus  and  the  bacillus  of  malignant 
cedcma  are  regidar  inhabitants  of  the  intestine  of  herbivorous  animals. 
The  micrococcus  lant'eolatus  has  been  found  repeatedly  in  the  human 
intestine,  likewise  the  bacillus  pyogenes  foetidus.  The  bacillus  aerogenes 
capsulatus  has  been  found  l)y  the  writer  in  the  intestine  in  two  cases  of 
perf)rative  peritonitis  with  |)rodnction  of  gas.  The  occurrence  of  intes- 
tinal actinomycosis  and  of  perityphlitis  actinomycotica  shows  that  the 
actinomyces  may  find  its  way  into  the  intestine. 

There  are  various  other  pathogenic  bacteria  which  have  been  occa- 
sionally found  in  the  intestine,  but  those  which  have  been  mentioned  ai'e 
the  ones  of  chief  surgical  interest.  The  specific  intestinal  infections  of 
typhoid  fever,  cholera,  tuberculosis,  and  antiirax  are  not  considered  here. 
The  amceba  dysenteri;e,  on  account  of  its  relation  to  abscess  of  the  liver 
and  lungs,  deserves  mention. 

In  this  connection  it  may  be  stated  that  the  bile  in  the  normal  bile- 
ducts  and  gall-bladder  is  to  be  regarded  as  free  from  bacteria.  Under 
various  conditions,  however,  the  colon  bacillus  and  other  Ijactcria,  par- 
ticularly the  ]>yogenic  cocci,  often  wander  into  the  biliary  passages.  The 
M'riter  has  found  very  frequently  the  colon  liaeillus  in  cultures  made  from 
the  interior  of  gall-stones.  It  is  not  uncommon  at  autopsies  to  find  the 
colon  bacillus,  less  .frequently  pyogenic  cocci,  particularly  streptococci, 
in  the  bile  without  any  alteration  in  the  bile  or  evident  lesion  to  exjdain 
the  migration  of  these  bacteria. 

Contrary  to  an  old  idea,  the  bile  has  not  been  found  to  possess  any 
decided  germii'idal  property,  at  least  as  regards  most  bacteria. 

Gexito-urixary  Tract. — It  has  been  shown  by  Lustgarten  and 
Mannaberg,  Rovsing,  Steinschneider  with  Galewsky,  Petit  and  Wassei'- 

'  Gillespie,  "  The  Bacteria  of  the  Stomach,"  The  Journal  of  Puthnlogy  and  Bacteriology, 
vol.  i.  p.  279.     Here  can  be  found  references  to  the  literature  of  this  suhject. 


266       GENERAL  BACTERIOLOGY  OF  SURGICAL  INFECTIONS. 

maun,  and  Hofmeister'  that  the  liealtliy  ma/e  urethra  always  contains 
hactcria.  These  are  abundant  and  varied  in  the  fossa  navi('uhiris,  and 
<liininis]i  rapidly  in  number  and  kind  toward  the  ])()sterior  j)art  of  the 
iiretlira.  JIow  far  l)aek  they  extend  is  not  ])ositively  known.  They 
were  found  l)y  Hofmeister  as  far  baek  as  eiii;ht  centimetres  from  the 
external  orifice  under  conditi(ms  making  it  proV)able  that  they  existed  at 
this  point,  and  were  not  simply  piislied  back  by  the  sterilized  glass  tube 
wliich  was  introduced  for  the  passage  of  the  inoculating  wire.  Urethral 
bacteria  are  usually  present  in  urine  voided  after  sterilization  of  the 
meatus  and  fossa,  even  in  the  urine  ])assed  toward  tlie  en<l  of  micturition. 

Lustgarten  and  Mamiabcrg  by  microscojiical  examination  of  the 
normal  male  urethra  distinguished  ten  ditferent  kinds  of  bacteria — 
namely,  four  bacilli  and  six  cocci.  Among  the  bacilli  was  the  smegma 
l)acillus,  which  has  already  been  mentioned  in  describing  the  bacteria  of 
the  skin  (page  254).  Among  the  cocci  was  a  diplococcus  M'hich  they 
descrilje  as  identical  in  form  and  staining  reactions  with  the  gonococcus. 
Tliey  isolated  in  cultures  seven  species  of  cocci,  white  and  yellow. 
Among  these  cocci  was  found  the  stajihylococcus  pyogenes  aureus.  They 
observed  that  the  common  urethral  saprophytes  were  ineajiable  of  causing 
ammoniacal  fermentation  of  the  urine,  and  that  they  died  when  planted 
in  urine. 

Rovsing,  in  opposition  to  most  other  investigators,  found  in  the 
normal  urethra  pyogenic  and  non-])yogenic  bacteria  cajiable  of  fermenting 
urine  and  identical  with  many  of  the  bacteria  found  in  cystitis,  so  that 
he  concludes  that  the  usual  source  of  the  bacteria  causing  cystitis  is  from 
the  urethral  flora  and  not  from  the  air  bacteria. 

Steinschneider  deseriljes  four  species  of  diplococci,  identical  with 
forms  previously  recognized  liy  Lustgarten  and  INIannaberg,  as  occurring 
in  the  normal  urethra.  Of  these,  a  milk-wliite  di])!ococcus,  which  was 
met  in  87  per  cent,  of  the  eighty-six  healthy  and  gonorrhreal  cases 
examined,  is  regarded  as  the  most  common  bacterium  of  the  urethra. 
Next  in  frequency  is  an  orange-yellow  dijilococeus  found  in  44.2  per 
cent,  of  the  cases.  These  two  sjiecies  are  stained  by  Gram's  method,  and 
need  not  be  confounded  with  the  gonococcus.  Steinschneider  isolated 
from  three  cases  a  grayisli-white  diplococcus,  and  from  one  case  a  lemon- 
yellow  diplococcus,  which  were  decolorized  by  Gram's  stain  and  which 
may  correspond  to  Lustgarten's  pseudo-gonococei.  He  concludes  that  in 
only  5  per  cent,  of  the  eases  are  diplococci  found  which  are  decolorized 
by  Gram. 

Petit  and  Wassermann,  whose  methods  were  ojien  to  objection,  culti- 
vated from  the  normal  uretlira  of  four  persons  five  cocci,  six  bacilli, 
two  sarcina?,  and  two  yeast-fungi.  They  did  not  find  a  pseudo-gono- 
coccus. 

Hofmeister  did  not  find  the  normal  urethral  flora  as  varied  as  have 
some  observers.  Two  species  of  di]ilococci — viz.  a  non-liquefving  white 
or  yellow,  large  coccus  and  a  li(juefving,  smaller,  gray  coccus — he  regards 
as  regular  inhabitants  of  the  urethra.  An  orange-yellow  and  an  opaque 
white  liquefying  dijilococcus  he  isolated,  eacli  from  two  cases.  None  of 
these  four  diplococci  from  recent  cultures  were  decolorized  by  Gram,  but 

'  Hofmeister,  Fortsichrilte  der  l\fi''lirli),  1893,  Nos.  16  and  17.  Keferences  to  otlier  arti- 
cles cited  are  contained  in  this  article. 


BACTERIA    OF  EXPOSED  ML'COUS  SURFACES.  267 

he  states  that  he  repeatedly  found  in  eover-elass  specimens  from  the  nre- 
tiiKi  diploeocei  which  were  decolorized  l)y  Cxram.  Once  he  found  the 
staphvlocoecus  aureus.  The  normal  urethral  Hora  he  considers  to  l)e 
non-})athogenic  and  incapable  of  surviving  long  in  the  urine,  although 
pathogenic  bacteria  may  accidentally  be  present  in  the  healthy  urethra. 

The  occurrence  of  the  so-called  psendo-gonococci,  as  tirst  descrilied 
by  Bumni  and  Lustgarten  and  Alannaberg  in  healthy  and  diseased  nre- 
thr:e,  is  of  importance  in  reference  to  the  diagnosis  of  gonorrhu'a  l)y 
microscopical  examination.  If  all  of  the  well-known  points,  as  to  the 
morphology,  staining  reactions,  and  enclosure  and  arrangement  within 
cells,  characterizing  the  gonococcus  be  observed,  most  autliorities  believe 
that  a  mistake  in  diagnosis  is  possible  only  in  a  very  small  number  of 
cases,  if  at  all.  Undouljtedly  a  microscopical  diagnosis  of  the  gouo- 
coccus  has  been  made  in  some  cases  uptin  insufficient  evidence,  and  it 
must  be  admitted  that  a  positive  microscopical  diagnosis  is  sometimes 
attended  with  great  difficulties.  "We  now  possess  methods  which  enable 
us  without  serious  practical  difficulties  to  isolate  and  study  the  gono- 
coccus in  cultures. 

It  cannot  be  said  that  investigations  have  determined  satisfactorily 
tlie  question  as  to  the  relative  frequency  with  which  the  bacteria  of  cys- 
titis are  derived  from  the  urethra  or  are  introduced  from  without  the 
body.  As  the  bacillus  eoli  communis  or  the  bacillus  lactis  aerogenes  is 
one  of  the  most  common  bacteria  in  cystitis,  the  infection  may  often  be 
from  the  intestinal  canal  through  the  blood-current  by  way  of  the  kid- 
neys; some  believe  more  directly  by  continuity  or  by  the  lymphatic  stream 
from  the  rectum.  These  bacilli  are,  however,  widely  distributed  outside 
of  the  body,  and  may  be  present  around  the  genitals. 

Although  the  results  of  the  bacteriological  examination  of  the  healthy 
urine  are  contradictory,  the  weight  of  evidence  is  decidedly  in  favor  of 
the  view  that  the  urine  in  the  bladder  in  health  is  free  from  bacteria, 
and  that  if  urethral  saprophytes,  or  .even  some  pathogenic  germs,  gain 
entrance  to  the  bladder,  they  do  not  long  survive  in  a  healthy  ])crson. 

The  female  urethra  contains  bacteria,  and  the  anatomical  conditions 
are  more  favoral)le  than  in  the  male  for  the  passage  of  the  urethral 
bacteria  into  the  bladder.  Von  Gawronsky  in  sixty-two  cases  examined 
found  bacteria  in  fifteen — namely,  the  streptococcus  pyogenes  (3),  the 
staphylococcus  aureus  (S),  sta])hylococcus  albus  (1),  the  bacillus  coli  com- 
munis (2),  the  bacillus  tholoeideum  (1).  This  last  bacillus  is  prol)ably  a 
pathogenic  variety  of  the  bacillus  lactis  aerogenes.  It  is  stated  that  the 
urethra  in  these  cases  was  normal. 

The  vagina  contains  bacteria  in  varying  number  and  kind.  The 
cervix  and  uterus  are  normally  free  from  bacteria.  The  absence  of  bac- 
teria from  the  uterus,  is  not  easily  explained,  but  it  has  its  analogy  in  the 
absence  of  bacteria  from  various  other  canals  and  cavities  which  com- 
nuuiicate  with  passages  containing  bacteria,  as,  for  example,  from  the 
bladder  and  the  bile-ducts.  The  factors  usually  cilcd  in  ex]ilanation  of 
this  important  provision  of  nature  are  mechanical  hinderances  to  the 
pencti'ation  of  bacteria  resulting  from  the  anatomical  structure  of  the 
parts  and  the  germicidal  jirojierties  of  the  secretions.  The  princiiud 
emphasis  is  usually  laid  upon  the  latter  factor. 

The  bacterial  flora  of  the  normal  vagina  contains  various  bacilli  and 


2C,9.       riEXERAL  BACTEnTOLOOY  OF  SURGICAL   INFECTIONS. 

cocci,  wliicli  do  not  <^row  on  onr  ordinary  cnltnro  media,  bnt  can  I)C  rec- 
ognized by  micro8ct)pical  examination.  Doederlcin '  lias  described  a 
non-])athogenic  bacillns  or  a  grouj)  of  bacilli  which  he  has  cultivated 
upon  a  sjM'cially  prepared  acid  medium,  and  which  are  characterized  by 
marked  acid  fermentation  of  sugar.  Tlicse  vaginal  bacilli  are  regarded 
by  Doederlcin  as  the  only  bacteria  to  be  found  regularly  in  the  normal 
vaginal  secretion,  and  u])on  their  jiresence  or  absence  he  has  l)asetl  his 
distinction  between  normal  and  pathological  vaginal  secretions.  It  has, 
however,  been  shown  by  Kriinig  and  Menge  that  Doedcrlein's  bacillus 
is  often  absent  from  the  normal  vagina,  and  that  it  cannot,  therefore, 
serve  as  a  distinguishing  character  of  the  normal  secretion. 

According  to  Knniig^and  JNlenge'' the  regular  bacterial  inhabitants 
of  the  normal  vagina  are  obligatory  anaerobes,  and  can  be  cultivated 
only  in  anaerobic  cultures.  Tiiey  do  not  describe  in  detail  the  characters 
of  these  vaginal  anaerobic  bacilli  and  cocci,  but  they  say  tliat  they  are 
non-pathogenic.  In  microscopical  jireparations  Mcnge  found  in  the 
normal  vaginal  secretion  of  non-pregnant  women  bacilli  more  abun- 
dantly than  cocci,  but  the  latter  were  never  missed.  He  found  Poeder- 
lein's  l)acilli  in  the  minority  of  cases,  and  more  frequently  short,  thick 
rods  and  delicate,  thin,  curved  rods. 

According  to  INIenge,  bacteria  capaljle  of  cultivation  in  alkaline 
aei'obic  culture  media  are  present  abundantly  near  the  outlet  of  the 
vagina,  but  are  usually  absent,  and  wlien  present  only  {'(^w,  in  the  ujiper 
part  of  the  normal  vagina.  He  found  tmly  once  out  of  fifty  cases  exam- 
ined a  pyogenic  coccus.  This  was  the  streptococcus  pyogenes,  wliicli 
existed  as  a  persistent  organism  throughout  the  vaginal  canal  of  a  non- 
])regnant  woman  with  gonorrhoea  of  the  cervix  and  thin  cervical  dis- 
charge.    The  reaction  of  the  vaginal  secretion  was  alkaline. 

Diplococci  similar  to  those  from  the  urethra  already  described  occur 
also  in  the  vagina,  and  what  was  said  in  that  connection  as  to  pseudo- 
gonocoeci  apjjlies  here.  Koplik*has  isolated  from  the  normal  vagina 
of  children  a  white  diplococcus,  and  from  the  \'aginal  discharge  in 
simj)le,  not  gonorrheal,  vulvo-vaginitis  in  children  two  white  diplo- 
cocci and  a  yellow  diplococcus.  None  of  these  were  decolorized  by 
Gram's  method  or  need  be  mistaken  for  the  gonococcus. 

The  question  as  to  the  occurrence  of  pathogenic  organisms  in  the 
normal  vagina  has  been  and  is  still  a  subject  of  vehement  contro\ersy 
among  obstetricians,  who  are  divided  into  two  camps  as  to  the  desira- 
bility of  antiseptic  irrigations  of  the  vagina  and  as  to  the  frequency  of 
so-called  auto-infection  as  a  cause  of  puerperal  infections.  The  question 
is  also  of  interest  to  the  surgeon  in  relation  to  hysterectomy  and  in 
general  to  operations  involving  the  vagina  and  uterus. 

The  results  of  different  investigators  on  this  point  have  been  ex- 
tremely divergent,  and,  notwithstanding  the  large  amount  of  work  done, 
it  is  not  possible  at  present  to  express  a  final  judgment.  Some  inves- 
tigators have  found  pyogenic  bacteria  frequently  in  the  vagina  of  preg- 
nant women.     Thus,  Stetfeck  found  pus-produciiig  organisms  in  41  per 

'  Doederlein,  Das  Scheithnsrkret,  v.  s.  w..  Leijizig,  1892. 

*  Kronig,  Deutsche  mrd.  Wochenschriff,  Oct.  25,  1894. 

3  Menge,  ibid.,  Nov.  15,  22,  29,  1894. 

■"  Kojilik,  Journal  of  Cuianeous  mid  Genilo-  Urinary  Diseases,  June  and  July,  1893. 


BACTERIA    OF  EXPOSED  3IUC0US  SURFACES.  269 

cent,  of  thf  twontv-nine  pregnant  women  examined.  Others  have  faik'tl 
to  find  pyogenic  bacteria,  with  tiie  exception  of  tiie  gonococcus,  in  all  of 
the  cases  examined,  or  have  met  them  only  exceptionally.  Most  of  the 
later  investigations  in  which  a  proju'r  technicjue  was  adopted  are  in 
accord  as  to  tiie  infreqnency  with  which  pathogenic  bacteria,  with  the 
exception  of  the  gonococcus,  are  to  be  found  in  the  vagina  of  either 
pregnant  or  non-j)regnant  women. 

In  a  bacteriological  examination  of  one  hundred  and  ninety-five  preg- 
nant women  Doederlein  found  in  55.3  per  cent,  acid  normal  vaginal 
secretion,  according  to  his  definition.  The  only  bacteria  were  tlie  acid- 
producing  vaginal  bacilli.  In  44. (J  per  cent,  of  the  cases  he  found  what 
he  calls  pathological  secretion,  which  was  feebly  acid,  neutral,  or  alka- 
line, and  contained  various  bacilli  and  cocci.  The  streptococcus  pyog- 
enes he  found  in  9.2  per  cent,  of  the  so-called  pathological  secretions, 
or  in  4.1  per  cent,  of  the  one  hundred  and  ninety-five  cases  examined. 
To  the  staphvlococci  present  he  attributes  no  imjHirtance  in  the  causation 
of  puerperal  fever.  The  oidium  albicans  is  often  finuid  in  the  vagina, 
but  is  without  significance  as  a  cause  of  primary  infection. 

Kronig  found  the  vaginal  secretion  of  all  the  pregnant  women  (about 
five  hundred)  whom  he  examined  to  be  acid,  the  intensity  of  the  reaction 
varying  in  different  cases.  The  bacterial  flora  was  of  the  same  general 
character  as  tliat  already  described  for  the  normal  vagina.  In  no  case 
did  he  find  the  streptococcus  pyogenes  or  pyogenic  staphylococci.  His 
conclusion,  that  the  streptococcus  pyogenes  and  the  ])yogenic  staphylo- 
cocci are  never  present  in  the  vagina  of  pregnant  women,  and  that  if 
they  should  enter  they  must  of  necessity  be  (juiekly  destroyed,  cannot 
Ije  accepted  without  discrediting  the  results  of  other  comjietent  investi- 
gators, but  we  may  admit  that  they  are  jiresent  only  exceptionally. 

Experiments  have  been  made  by  Kronig  and  Menge  proving  tliat 
bacteria,  including  the  streptococcus  pyogenes  and  jiyogenic  staphylo- 
cocci, introduced,  even  in  large  number,  into  the  vagina  of  ])regnant  or 
non-pregnant  women,  disap))ear  in  a  short  time.  Thus,  Kriuiig  found 
that  the  bacillus  pyocyaneus  disappeared  from  the  vagina  of  pregnant 
women  in  from  ten  to  thirty  hours,  the  staphylococci  in  from  six  to 
thirty-six  hours,  and  the  streptococcus  ])yogenes,  with  which  only  three 
experiments  were  made,  within  six  hours.  No  difference  \\as  observed, 
as  to  the  rapidity  with  which  these  foreign  organisms  disajipeared, 
between  the  normal  and  pathological  secretions  in  Poederlein's  sense, 
including  those  containing  gonococci.  Wenge  found  in  non-pregnant 
women  that  the  V)acillus  pyocyaneus  disapjieared  from  the  vagina  on  the 
average  in  twenty-one  hours,  the  staphylococcus  jn'ogenes  aureus  in 
twenty-six  hours,  aod  the  streptococcus  pyogenes  in  twenty-two  hours. 
In  only  one  case  did  the  vagina  become  infected,  and  this  was  with  the 
sta]ihylococcus  aureus  in  consequence  of  an  accidental  injury  to  the  wall. 
In  the  other  cases  the  bacteria  immediately  after  their  introiUiction  began 
to  disappear.  In  most  instances  an  increase  in  the  leucocytes  in  the 
vagina  was  ol:)served. 

Menge  has  attempted  to  discover  the  factors  concerned  in  the  pro- 
duction of  this  powerful  bactericidal  property  of  the  vaginal  secretion. 
He  attaches  some  importance  to  the  acid  reaction  to  which  Doederlein 
had  called  attention  as  the  essential  factor,  but  this  cannot  be  the  sole  or 


270       GENERAL  BACTERIOLOGY  OF  SURGICAL  INFECTIONS. 

tlic  principal  faotcir,  as  tlio  vaginal  secretion  of  non-i)r("gnant  women, 
altluiuti'li  usually  acid,  may  he  alUaline,  anil  the  bacteria  (lisaj)peare(l 
ahdut  as  rapidly  from  the  alkaline  as  from  the  acid  secretion.  AVe 
cannot  at  present  give  any  satisfactory  explanation  of  the  bactericidal 
properties  of  the  vaginal  secretion. 

Irrigation  of  the  viigina  with  water  or  with  antiseptics  diminished 
the  rapidit}'  with  which  bacteria  intnxluced  into  the  vagina  disap- 
peared. 

Bacteria  introduci'd  into  the  cervix  uteri  likewise  disappeared  in  a 
short  time.     The  secretion  here  is  alkaline. 

As  a  result  of  the  investigations  of  numerous  observers  we  mav  con- 
clude that  the  normal  vagina  of  pregnant  and  non-pregnant  women  may 
contain  ])athogenic  bacteria.  With  the  exception  of  the  gonococcus, 
such  Ijacteria  are  not  often  jiresent,  and  the  vaginal  secretion  does  not, 
as  a  rule,  permit  the  prolonged  survival  of  most  of  the  bacteria,  includ- 
ing pathogenic  forms,  which  may  enter.  Powerful  as  these  normal  de- 
fences ai'c,  they  may,  however,  be  overthrown  imder  conditions  which 
we  now  only  imperfectly  understand. 

IMucli  emphasis  has  been  laid  upon  the  fact  that  jnogcnic  cocci  occa- 
sionally found  in  the  vagina  iiave  manifested,  with  few  exceptions,  little 
or  no  virulence  when  inoculated  into  animals.  It  should,  however,  be 
remarked  that  the  same  negative  result  of  the  animal  experiment  some- 
times follows  the  inoculation  of  streptococci  cultivated  from  cases  of 
jnierperal  infection.  The  animal  ex])criment  is  not  decisive  as  to  the 
possibilities  of  these  pyogenic  bacteria  in  man,  and  it  has  been  jiroven 
that  ])yogenic  cocci  without  virulence  for  animals  mav  infect  human 
beings.' 

Bacteria  in  Woman's  Milk. — Serious  errors  of  interpretation  of 
their  observations  have  been  made  by  several  investigators  of  the  subject 
of  excretion  of  bacteria  by  the  milk,  by  not  recognizing  the  fact  that  milk 
obtained  from  the  breasts  of  healthy  women  regularly  contains  bacteria. 
The  milk  as  secreted  by  the  gland  is  undoubti'dly  sterile  in  health,  but 
bacteria  derived  from  the  skin  are  mingled  with  the  milk.  These  bac- 
teria gain  access  to  the  milk  in  the  lacteal  ducts  within  the  nipjile.  By 
far  the  most  common  of  these  bacteria  is  the  staphjloeoccus  epidermidis 
albus,  described  by  investigators  of  this  subject  as  the  staphylococcus 
pyogenes  albus.  This  coccus  is  a  regular  inhabitant  of  the  milk  in  the 
lacteal  ducts  near  their  outlets.  Surprise  has  been  expressed  liy  Honig- 
mann-  and  others  that  of  all  the  cutaneous  bacteria  this  should  be  usually 
the  predominant  or  the  only  one  found  in  the  milk,  but  it  appears  to  the 
writer  that  his  investigations  as  to  the  behavior  of  this  organism  in  the 
skin  explains  satisfactorily  the  appearance  of  this  coccus  in  the  milk. 
Of  all  the  cutaneous  bacteria,  this  is  the  only  one  which  penetrates  regu- 
larly into  the  deeper  layers  of  the  epidermis  and  into  the  glandular 
appendages  of  the  skin.  Occasionally  other  bacteria,  also  derived  from 
the  skin,  are  present  in  the  milk.     The  staphylococcus  pvogenes  aureus 

'  A  full  review  of  the  baeteriolnsical  literature  of  the  subject  of  puerperal  auto-Infec- 
tion up  to  the  date  of  its  pulilieation,  together  with  the  re])ort  of  original  observations, 
will  he  found  in  a  jiaper  by  J.  Wliitridge  Williams  in  The  American  Journal  of  the  Med- 
ical Sciences,  .July,  1893. 

'Honigmunn,  ZcUschriJt  fur  Hygiene,  Bd.  xiv.  p.  207. 


SOURCES  OF  THE  BACTERIA  I\  SURGICAL  INFECTIONS      271 

has  been  found  in  tlie  milk  of  healtliy  women  in  a  number  of 
instanocs. 

It  is  not  Ivuown  liow  far  up  the  lacteal  ducts  this  normal  bacterial 
flora  extends.  It  is  probable  that  the  mammary  gland  conforms  in  this 
matter  to  the  behavior  of  other  ghiuds  wliose  duets  open  upon  surfaces 
containing  bacteria,  and  that  bacteria  in  demonstrable  number  are  found 
only  in  the  excretory  ducts  near  their  outlets. 

As  the  staphylococci  normally  present  in  the  milk  have  the  property 
of  coagulating  milk,  it  can  hardly  be  tiiat  any  considerable  multiplication 
of  these  bacteria  occurs  in  tiie  milk  within  the  lacteal  ducts.  Fokker 
observed  a  limited  germicidal  effect  of  fresh  milk  in  some  cases,  but 
Honigniann  in  a  larger  number  of  experiments  with  proper  technique 
was  unable  to  determine  any  such  property,  even  as  regards  the  typhoid 
and  the  cholera  bacilli,  which  are  readily  killed  by  blood-serum. 

Sources  of  the  Bacteria  in  Surgical  Infections. 

Internal  Sources. — We  have  learned  that  pathogenic  bacteria,  and 
particularly  the  pyogenic  micrococci,  may  be  present  upon  the  skin  and 
various  exposed  mucous  membranes  of  healthy  human  beings.  These 
bacteria  are  of  course  derived  primarily  from  external  sources,  but  some 
of  them  may  live  for  a  long  time  or  indefinitely  on  exposed  sui'faces  of 
the  l)ody,  and  are  found  here  so  often  that  it  is  proj^er  to  recognize  the 
patient's  own  body  as  one  source  of  the  bacteria  concerned  in  surgical 
infections. 

Internal  sources  of  wound-infection  are  in  general  less  commonly 
operative  and  less  dangerous  than  the  external  sources.  One  explanation 
of  this  is  that  the  pyogenic  bacteria  commonly  found  in  the  healthy  body 
are  often  less  virulent  than  those  derived  from  many  external  sources. 
Tlie  streptococcus  pyogenes  when  cultiv;ited  from  healthy  nuicous  mem- 
branes is  often  of  very  slight  or  no  virulence,  as  tested  upon  animals, 
although  occasionally  highly  virulent  streptococci  are  found  under  these 
circumstances.  The  pyogenic  staphylococci,  and  particulai-ly  the  sta- 
phylococcus albus,  are  often  of  greatly  attenuated  virulence  when  isolated 
from  the  ex}iosed  surfaces  of  healthy  persons.  The  lanceolate  micro- 
coccus is  present  in  a  virulent  state  in  the  mouths  of  only  about  15  per 
cent,  of  healthy  persons,  although  it  is  oftener  present  in  a  non-virulent 
condition.  The  bacillus  coli  communis  obtained  from  healthy  fffices  is 
usually  of  very  slight  pathogenic  power. 

There  are  various  influences  wliich  may  be  cited  to  explain  tin; 
relatively  sligiit  virulence  of  many  of  the  jKithogenic  bacteria  present  in 
the  healthy  body.  Among  the  most  a])parent  are  the  struggle  for  exist- 
ence with  the  regulaf  saprojihy-tic  flora  of  the  body,  the  influence  of  the 
products  of  the  latter  organisms,  and  especially  the  antiliacterial  proper- 
ties of  the  fluids,  secretions,  and  living  cells  of  the  body.  That  under 
circumstances  which  we  at  present  little  understand  the  bacteria  of  the 
Ijodv  mav  ac(|uire  unwonted  virulence  seems  certain. 

ilighiv  virulent  staphvlococci  and  streptococci  may  be  present  on  the 
exposed  surfaces  of  the  healtliy  body  without  doing  any  harm.  The  pro- 
tection of  the  body  from  infection  with  the  pathogenic  bacteria  which  it 
often  harbors  is  due  not  so  much  to  the  lowered  virulence  of  these  bac- 


272       GENERAL  BACTERIOLOGY  OF  SURGICAL  INFECTIONS. 

teria  as  to  the  defences  wliicli  liave  been  set  up  against  tlieir  invasion  and 
to  tiie  loeal  and  general  resistance  offered  to  their  growth. 

These  defences  may,  however,  he  overthrown,  and  luider  tliese  cir- 
cinnstances  patiiogenic  bacteria  originally  {)rcsent  on  exposed  surfaces  of 
the  IxkIv  may  cause  various  loeal  and  general  diseases.  The  unsatisfac- 
tory term  "  auto-infection "  is  sometimes  applied  to  diseases  thus  pro- 
duced. 

The  internal  organs  and  fluids  of  the  healthy  body  are  normallv  free 
from  bacteria.  Bizzozero  and  Kibhert  have  found  bacteria,  often  Avithin 
cells,  regularly  in  the  lymph-follicles  of  the  normal  rabbit's  cieeuni,  and 
Bizzozero  has  found  spirilla  often  in  the  e])ithelial  cells  lining  the  necks 
of  the  gastric  tubules  in  dogs.  These  are  the  oidy  examples  known  of 
the  presence  of  bacteria  in  the  living  cells  of  the  jjcrfectly  healthy  l)ody, 
and  here  the  bacteria  have  penetrated  only  a  short  distance  beneath  the 
free  surface. 

It  is  probable  that  pathogenic  as  well  as  other  bacteria  occasionally 
get  into  the  tissues  and  circulation  of  healthy  persons  without  doing  any 
harm.  It  is  claimed  by  some  that  the  invasion  of  bacteria  into  the 
healthy  body  is  not  unc^ommon,  and  this  d((ctrine  is  called  latent  micro- 
bism by  some  French  writers.  The  occasional  t)ccurrence  of  supjjuration 
in  a  simple  fracture  of  bone  or  in  other  injured  parts  remote  from  an 
exposed  surface  is  best  explained,  at  least  in  many  cases,  by  the  lodge- 
ment of  pyogenic  bacteria  which  have  been  carried  from  an  exposed  sur- 
face to  the  part  by  the  blood  or  lymphatic  current,  and  which  j)resumably 
would  have  done  no  harm  without  the  presence  of  a  locus  minoris  resist- 
entiffi.  The  infrequency  of  this  event,  however,  indicates  that  the  pres- 
ence of  pathogenic  bacteria  in  the  internal  organs  and  fluids  of  the  healthy 
body  is  exceptional. 

Can  a  wound  become  infected  by  liacteria  conveyed  to  it  by  the 
circulating  blood?  This  may  happen  in  individuals  already  infected, 
although,  even  when  it  is  certain  that  pyogenic  cocci  are  present  in  the 
circulating  blood,  a  wound  may  heal  without  suppuration.  The  possi- 
bility of  the  infection  of  a  wound  in  a  previously  uninfected  person  by 
bacteria  conveyed  by  the  blood-current  cannot  lie  denied,  but  we  possess 
no  stringent  proof  of  such  an  occurrence,  and  all  experience  goes  to  show 
that  wound-infection  from  this  source  must  be  very  exceptional,  if  it 
occurs  at  all. 

AA'ith  jiroper  technique  the  surgeon  has,  as  a  rule,  little  to  fear  from 
the  bacteria  of  the  patient's  skin  as  a  source  of  infection  of  operative 
wounds.  The  only  bacterium  of  the  skin  which  is  not  usually  destroyed 
by  thorough  disinfection  of  the  surface  is  the  staphylococcus  e])idermidis 
albus,  which  lies  often  deeper  than  can  be  reached  by  any  of  the  prac- 
ticable methods  of  cutaneous  disinfection.  This  coccus  is  found  with 
great  frequency  in  wounds  treated  asej)tically  or  antiseptically,  but  ordi- 
narily it  does  not  interfere  with  the  process  of  repair.  Under  certain 
circumstances,  particularly  mIicu  foreign  bodies  are  introduced  into  the 
wound  or  when  there  is  strangulated  tissue  in  the  wound,  it  may  cause 
rise  of  temperature  and  sup])uration.  It  is  the  most  common  cause  of 
stitch-abscesses.  It  is  often  associated  with  otiier  bacteria  in  suppura- 
tion of  external  wounds  and  in  inflammations  involving  the  skin.  It  is 
identical  with,  or  simj)ly  a  variety  of,  the  staphylococcus  pyogenes  albus, 


SOURCES  OF  THE  BACTERIA  IN  SURGICAL  INFECTIONS      273 

but  for  reasons  which  have  been  stated  the  latter  name  seems  inappro- 
priate for  this  ordinary,  harmless  skin  coccus.  This  white  staphylo- 
coccus is  a  widely-distributed  organism,  and  it  may  enter  a  Avouud  from 
witiii.Hit  as  well  as  directly  from  the  surface  of  the  body. 

The  source  of  the  bacillus  pyocyaneus  in  wounds  is  often  from  the 
skin  of  the  patient,  but  this  is  a  widely-distributed  organism,  and  it 
may  also  enter  from  without. 

The  mucous  membranes  which  normally  harbor  bacteria  on  their  sur- 
face cannot  be  completely  disinfected  by  any  practicable  methods,  al- 
though it  is  possible  to  reduce  the  number  of  bacteria,  in  some  situa- 
tions more  readily  than  in  others.  The  utility  of  attempting  before 
operation  disinfection  of  a  mucous  surface — as,  for  example,  in  opera- 
tions involving  the  conjunctiva,  mouth,  rectum,  and  the  lower  genito- 
urinarv  tract — must  be  determined  by  experience,  and  on  this  point  the 
views  of  surgeons  are  not  in  harmony. 

Bacteria  cannot  be  completely  kept  out  of  wounds  of  exposed  mucous 
membranes.  The  kinds  of  bacteria  in  the  patient's  body  which  are 
likely  to  enter  such  wounds  and  the  special  conditions  relating  to  tiie 
bacterial  flora  of  the  ditferent  mucous  membranes  ha\'e  already  been 
described.  Although  wounds  involving  such  mucous  membranes  as  those 
of  the  mouth  and  intestine,  Mdiich  contain  vast  numbers  of  bacteria, 
including  often  |)yogenic  varieties,  often  heal  satisfiictorily,  and  even  by 
first  intention,  the  surgeon  has  no  such  guarantee  of  securing  primary 
union  as  in  operative  wounds  through  the  slvin.  The  fact  that  these 
Avounds  often  heal  quickly  and  without  suppuration  demonstrates  that 
the  mere  presence  of  certain  bacteria,  even  in  large  number,  in  a  wound 
does  not  necessarily  interfere  witii  healing.  It  also  supports  the  view 
already  advocated  that  the  pyogenic  cocci  often  present  on  certain  exposed 
mucous  surfaces  are  usually  of  weakened  virulence.  But  tiie  main  factor 
is,  after  all,  the  vital  resistance  of  the  living  tissues  to  bacteria,  including 
many  virulent  species. 

The  pathogenic  bacteria  often  present  on  the  exposed  surfaces  of  the 
healthy  body  are,  however,  of  surgical  interest,  not  so  much  as  a  source 
of  primary  wound-infection,  but  ratiier  as  the  specific  agents  of  infection 
in  various  local  and  general  surgical  diseases.  As  examples  of  local 
diseases  of  tiiis  category  may  be  cated  otitis  media,  appendicitis,  per- 
forative and  other  forms  of  ptn-itonitis,  some  cases  of  cystitis,  and  cer- 
tain abscesses.  The  pneumonias,  localized  abscesses,  pysemia,  and  sej)- 
ticsemia  which  are  such  fret[uent  complications  of  diphtheria  and  certain 
general  diseases,  as  typhoid  fever  and  other  infectious  fevers,  are  due  in 
many  instances  to  the  secondary  invasion  of  pathogenic  bacteria,  par- 
ticularly pyogenic  cocci,  normally  jiresent  on  mucous  membranes.  It  is 
chiefly  from  the  mouth,  tonsils, -pharynx,  and  intestine  that  these  invaders 
enter  the  body.  The  primary  disease  is  often  one  which  is  attended  by 
some  lesion  of  the  mucous  membrane  which  opens  the  way  for  the  pass- 
age of  the  micro-ors;anism.  But  it  is  not  enough  for  the  o-ate  to  be 
thrown  open.  The  defenders  within  must  be  overcome.  Hence  it  is 
particularly  in  conditions  where  the  vital  powers  of  resistance  are  lowered 
that  we  meet  with  affections  caused  by  the  invasion  of  pyogenic  bacteria 
from  the  exposed  surfaces  of  the  body.     That  under  these  conditions,  as 

Vol.  I.— is 


274       GENERAL  BACTERIOLOGY  OF  SURGICAL  INFECTIONS. 

well  as  under  otliers,  attomuitcd  bacteria  of  the  body  may  become  exalted 
in  virulence  is  liiolily  probable. 

The  term  "  auto-inlcction  "  is  associated  particularly  with  the  discus- 
sions on  the  causation  of  puerperal  fever.  The  bacteriological  data 
entering  into  this  discussion  have  Ixicn  given  in  describing  the  bacteria 
of  the  vagina.  The  evidence!  is  contradie^tory,  but  on  the  Avhole  is 
opposed  to  recognizing  so-called  auto-infection  as  a  cause  of  ])Uerp('ral 
fever,  save  in  a  small  proportion  of  cases. 

The  bacteria  most  often  foinid  in  cystitis  are  such  as  might  readily 
gain  entrance  at  times  to  the  healthy  urethra,  but  in  most  cases  of  this 
disease,  as  in  so  many  others,  an  essential  etiological  factor  is  some  pri- 
mary damage  to  the  part,  which  permits  the  survival  and  growth  of  the 
invading  micro-organisms. 

The  most  common  secondary  in\-ader  of  the  body  is  the  bacillus  coli 
communis.  The  first  observations  of  the  general  invasion  of  the  inter- 
nal organs  of  the  body  t)y  the  colon  bacillus  were  made  by  the  writer 
and  reported  in  May,  1890.  We  have  found  in  40  per  cent,  of  the 
autopsies  at  the  Johns  Hopkins  Hospital  the  colon  bacillus  in  one  or 
more  of  the  internal  organs,  those  most  frequently  invaded  being  tlie 
lungs,  kidneys,  liver,  mesenteric  glands,  and  gall-bladder.  In  the  great 
majority  of  these  cases  the  colon  Ijacilli  were  present  \\ithout  any 
organic  lesion  which  could  be  referred  to  them.  Intestinal  lesions 
were  found  in  75  per  cent,  of  our  post-mortem  cases  of  invasion  of  the 
colon  bacillus.  Very  little  importance  is  to  be  attached  to  the  demon- 
stration of  this  bacillus  in  internal  organs  of  the  body  at  autopsies  in 
cases  without  any  lesion  ■which  can  be  referred  to  it. 

The  fact  that  the  colon  bacillus  is  found  with  great  frequency  in 
internal  organs  of  the  body  after  death  from  all  sorts  of  causes,  and 
without  doing  any  manifest  injury,  necessitates  caution  in  the  interpreta- 
tion of  cases  where  its  presence  is  associated  with  definite  lesions.  That 
in  some  of  the  cases  reported  as  infections  by  this  bacillus  its  presence 
was  only  that  of  an  accidental,  secondary  invader  seems  to  the  writer 
certain.  '  There  can  be  no  doubt,  however,  that  under  certain  conditions 
the  colon  bacillus  may  be  pathogenic.  It  is  prone  to  settle  in  jtarts 
already  damaged  either  by  some  other  micro-organism  or  by  some  non- 
infectious agent.  In  forty-eight  cases  of  acute  inflammation,  of  various 
kinds  and  situations,  in  which  we  found  the  colon  bacillus,  it  was  the 
sole  organism  ])resent  in  only  fourteen.  In  the  majority  of  cases  of 
appendicitis  and  of  perforative  jieritonitis  we  have  found  associated  with 
the  colon  bacillus  other  bacteria,  and  particularly  the  ordinary  pyogenic 
cocci.  There  is  reason  to  believe  that  the  highly  i-esistant  colon  l)acillus 
may  survive  in  an  inflamed  part  after  the  primary  organism  which 
started  the  trouble  has  died  out  or  has  l)een  crowded  out  by  the  invader. 

The  colon  bacillus  has  been  repeatedly  observed  alone  or  in  combina- 
tion with  other  bacteria  in  wounds.  That  it  may  be  the  primary  infec- 
tious agent  in  various  surgical  and  other  inflannnations  in  different  parts 
of  the  body  is  established  by  numerous  observations. 

The  bacillus  lactis  aerogenes,  which  most  investigators  no  longer 
attempt  to  separate  sharply  from  the  bacillus  coli  communis,  is  likewise 
a  common  invader  from  the  intestinal  tract  under  conditions  similar  to 
those  relating  to  the  colon  bacillus  and  with  similar  pathogenic  effects. 


SOURCES  OF  THE  BACTERIA  IN  SURGICAL  INFECTIONS.      275 

The  streptococcus  pyogenes  is  a  far  more  important  cause  of  surgical 
infections  than  is  the  colon  bacilhis.  It  is  more  commonly  present  than 
other  pyogenic  cocci  in  appendicitis,  peritonitis,  and  other  inflannnations 
of  serous  meaihranes,  and  in  septic  infections  secondary  to  other  diseases. 
It  is  a  frequent  cause  of  secondary  inflammations  in  the  lungs,  serous 
membranes,  and  other  parts,  and  of  general  septictemia  in  diphtheria, 
tuberculosis,  scarlet  fever,  typhoid  fever,  and  other  infectious  fevers,  and 
also  in  many  non-infectious  diseases.  The  source  of  these  various  second- 
ary streptococcus  infections  is  often  from  the  mouth,  tonsils,  throat,  and 
intestine,  parts  which  in  their  normal  condition  often  harbor  strei)toeocci. 

Of  (ither  bacteria  more  or  k'ss  frequently  present  on  exposed  surfaces 
in  health,  and  concerned  in  various  surgical  infections,  may  be  especially 
mentioned  the  staphylococcus  aureus  and  albus,  the  micrococcus  lanceo- 
latus,  the  bacillus  pyocyaneus,  the  micrococcus  tetragenus,  bacillus  pro- 
teus,  and  the  bacillus  of  Friedliinder. 

External  Sources. — Bacteria  derived  from  without  the  body,  are 
those  chiefly  concerned  in  infections  of  wounds  and  most  other  primary 
surgical  infections.  Abundant  experience  has  demonstrated  that  if  all 
patliogenic  bacteria  from  external  sources,  as  well  as  those  which  may 
happen  to  be  upon  the  surface  of  the  skin,  be  kept  out  of  an  external 
wound,  no  suitpuration  of  the  wound  occurs. 

There  airt  two  ways  by  which  external  bacteria  may  enter  a  wound: 
one  is  by  contact  \vith  objects  contaminated  with  bacteria ;  the  other  is 
by  the  air.  Strictly  speaking,  air  infection  is  also  contact  infection,  but 
the  distinction  implied  in  the  customary  use  of  these  terms  is  a  useful 
one.  Experimental  and  clinical  observations  have  shown  conclusively 
that  contact  infection  is  far  more  dangerous  and  common  than  air 
infection. 

The  main  emphasis  of  modern  surgical  technique  is  laid  upon  the 
sterilization  of  all  objects,  such  as  instruments,  ligatures,  dressings,  and 
the  hands  of  operator  and  assistants,  which  are  brought  into  contact  with 
the  wound.  The  principal  sources  of  contact  infection  of  wounds,  as 
enumerated  by  Park,'  are  the  skin  and  hair,  instruments,  sponges  or 
their  substitutes,  suture  material,  tlie  hands  of  the  surgeon  and  his  assist- 
ants, drainage  materials,  dressing  materials,  miscellaneous — c.  g.  drops 
of  perspiration,  an  unclean  irrigator-nozzle,  the  nail-brush,  tlie  clothing 
of  the  O])erator  or  the  bystanders,  etc.  Of  these  objects  the  most  difficult 
to  disinfect  is  the  skin.  We  have  already  considered  this  subject,  so  far 
as  it  belongs  to  this  article,  in  describing  the  bacteria  of  the  skin. 

The  pyogenic  cocci,  which  are  the  bacteria  concerned  in  the  great 
majority  of  cases  of  wound-infection,  are  ubi(piitous,  and  it  would  be 
useless  to  attempt  to  specify  all  the  objects  upon  which  they  have  been 
found.  The  source  from  which  tiiese  cocci  are  derived  is  not,  however, 
a  matter  of  indifference.  The  jjyogenic  cocci,  and  particularly  the  strej)- 
tococcus,  derived  from  infected  persons,  as  from  a  case  of  erysipelas  or 
peritonitis  or  septiciiemia,  are  more  likely  to  cause  serious  infection  of 
wounds  than  cocci  of  the  same  sjM^cies  derived  from  other  sources. 

Of  other  bacteria  sometimes  concerned  in  wound-infe(^tion,  the  bacillus 
coli  communis  not  only  is  a  constant  inhabitant  of  the  normal  intestine, 

'Eoswell  Park,  "Wound-infection,"  American  Journal  of  the  Medical  Sciences,  Nov., 
1891. 


276        GENERAL  BACTERIOLOGY  OF  SURGICAL  INFECTIONS. 

but  is  widely  distributed  in  cxtcnial  uaturc,  and  the  bacillus  pyoeyu- 
lUMis,  often  present  on  tlie  iiealtliy  skin,  is  likewise  a  Midely-dis- 
tributed  organism.  The  bacillus  j)y()cyaneus  is  a  comparatively  harm- 
less organism  in  external  wounds,  but  it  is  capable  of  exerting  serious 
pathogenic  activity,  especially  in  infections  from  the  intestine.  The 
soil  is  the  natural  home  of  the  tetanus  bacillus,  whicli  is  abundant  in 
certain  localities  and  rare  in  other  places.  It  has  been  found  with 
especial  frequency  in  garden  earth  and  about  stables.  It  is  present  very 
commonly  in  the  fteces  of  herbivorous  animals,  as  has  already  been  men- 
tioned. Sormani  observed  that  tetanogenic  material  introduced  into  the 
alimentary  canal  of  dogs,  which  subsecpiently  were  prevented  from 
receiving  additional  tetanus  l)acilli,  could  be  demonstrated  as  long  as 
sixteen  days  after  its  recejition.  The  bacillus  of  malignant  tedema  is 
likewise  a  common  inhabitant  of  the  soil.  In  infected  localities  the 
anthrax  bacillus  lives  in  the  soil.  In  fact,  the  upper  layers  of  the  soil 
are  the  great  home  of  bacteria  of  all  sorts,  and  pyogenic  cocci  have 
been  found  in  this  situation.  The  proteus  bacillus,  which  is  cajiabh'  of 
assuming  pathogenic  activity,  is  commonly  found  in  decomjMsing  animal 
substances. 

Flies  and  other  insects  may  l)c  the  carriers  of  all  sorts  of  infectious 
agents.  Pyogenic  staphylococci  have  been  found  in  the  excrements  of 
flies,  and  even  the  susceptible  cholera  bacillus  jjasses  unharmed  through 
the  alimentary  canal  of  flies. 

Certain  surgical  infections  are  associated  particularly  with  injuries 
from  definite  objects,  as,  for  example,  necrogenic  warts,  containing  tuber- 
cle Itacilli,  from  cadavers ;  zoonotic  erysipeloid  from  crabs  and  other 
shellfish ;  oyster-shucker's  keratitis ;  actinomycosis  from  oats  and  other 
grains  ;  anthrax  from  hides,  wool-sorting,  and  other  handling  of  material 
from  infected  animals. 

It  has  been  demonstrated  by  La  Garde  ^  that  bullets  obtained  from 
previously  unopened  boxes  as  sent  out  by  the  manufacturer  are  ]>raetically 
sterile,  but  that  if  the  bullets  become  contaminated  with  pathogenic 
bacteria,  the  latter  are  not  destroyed  in  the  discharge  and  transit  of  the 
bullet,  and  are  capable  of  infecting  wounds.  He  was  able  to  infect  rab- 
bits with  the  streptococcus  pyogenes  and  other  jiathogenic  bacteria  by 
firing  infected  bullets  through  the  ear. 

As  compared  with  contact  infection,  infection  of  wounds  from  the  air 
is  of  minor  importance,  but  surgeons  are  not  agreed  as  to  whether  or  not 
the  dangers  of  air  infection  are  so  slight  under  ordinary  conditions  that 
they  need  not  be  taken  into  consideration  at  all.  In  the  early  days  of 
antiseptic  surgery  bacteria  of  the  air  Mere  thought  to  be  frequent  agents 
of  wound-infection  and  the  carbolic  s]iray  was  introduced  Ijy  Lister  with 
the  intention  of  destroying  them.  There  followed  a  period  when  sur- 
geons considered  that  the  air  bacteria  could  be  wholly  neglected  as  a 
source  of  traumatic  infection,  and  this  is  probably  still  the  opinion  of  the 
majority  of  surgeons.  At  present  there  is  a  tendency  again  to  pay  more 
attention  to  the  possibilities  of  infection  from  this  source,  and  some  sur- 
geons have  even  gone  back  to  the  use  of  the  spray. 

Bacteria  are  always  present  in  the  air  over  the  ground  and  around 
human  habitations,  whereas  sea-air  at  a  considerable  distance  from  land 

'  La  Garde,  New  York  Medical  Journal,  Oct.  22,  1892. 


SOURCES  OF  THE  BACTERIA  IN  SURGICAL  INFECTIONS.      277 

and  the  air  at  high  altitudes  is  nearly  or  quite  free  from  micro-organisms. 
Bacteria  do  not  usually  occur  in  the  air  as  single,  detached  cells,  but 
ratiicr  as  clumps  attached  to  particles  of  dust,  so  that  in  a  perfectly 
quiet  atmosphere,  as  in  a  closed  room,  these  particles  containing  bacteria 
rapidly  settle  upon  underlying  objects.  Bacteria,  being  thus  attaclied  to 
particles  of  dust,  are  readily  filtered  out  from  the  air  by  passing  it 
through  porous  substances,  such  as  cotton-wool.  The  bacteria  are  car- 
ried down  by  drops  of  rain,  and  the  air  of  a  room  may  be  freed  from 
floating  bacteria  by  producing  an  artificial  rain  by  some  form  of  douche 
or  s|)ray  a[)paratus. 

Whatever  creates  dust,  such  as  tlie  entrance  or  exit  of  a  body  of 
students,  and  other  movements  in  a  room,  brings  bacteria  into  the  air. 

It  is  a  fact  of  fundamental  hygienic  importance  that  fine  particles, 
including  bacteria,  are  not  detaciied  from  moist  surfaces  even  by  strong 
currents  of  air.  Hence  conies  the  iiygienic  value  of  using  moist  cloths 
in  removing  dust  and  in  cleansing  a  room.  Substances  containing 
infected  material  sliould  not  be  allowed  to  dry  under  conditions  in 
whii'h  dust  therefrom  can  be  conveyed  into  the  air.  In  the  present  era 
of  dry  dressings  for  wounds  there  is  frequent  opportunity  for  the  scatter- 
ing of  dust  from  the  discharges  dried  on  the  dressings  in  the  removal 
and  snbsecpient  handling  of  these  dressings,  unless  especial  care  be 
tid^en  to  pi-event  this  in  all  cases  where  pathogenic  bacteria  may  be 
present. 

Tlie  number  of  bacteria  in  the  air  varies  greatly  under  different  con- 
ditions. In  general  it  may  be  said  that  living  micro-organisms  are  less 
abiuulant  in  the  air  than  was  formerly  supposed.  They  cannot  multiply 
in  the  air,  and  only  those  whose  vitality  is  not  destroyed  by  drying  can 
exist  in  the  air.  Desiccation  may  lessen  the  virulence  of  pathogenic  bac- 
teria without  actually  destroying  them. 

Wiiat  interests  us  chiefly  in  this  connection  is  to  know  whether  patho- 
genic bacteria,  and  more  particularly  tiie  pyogenic  cocci,  occur  in  the 
air,  and,  if  so,  how  frequently  and  under  what  conditions. 

Pyogenic  staphylococci  and  strejitococci  have  been  repeatedly  found  in 
the  air,  althougli  generally  only  in  small  number.  Olttaincd  from  this 
.source,  these  cocci  are  often  of  only  sligiit  virulence,  but  highly  virulent 
sta])hylococci  and  streptococci  have  been  isolated  from  the  air.  Among 
those  \vho  have  isolated  pyogenic  cocci  from  the  air  may  be  especially 
mentioned  von  Eiselsberg,  Emmerich,  Neumann,  Prudden,  Ullmann, 
Ilaegler,  C.  Fraenkel.  Haegler '  demonstrated  that  streptococci  may 
j)reserve  their  vitality  and  power  of  development  for  at  least  thirty- 
six  days,  and  staphylococci  for  one  hundred  days,  in  pus  dried  on 
bandages. 

Pyogenic  staphylococci  and  streptococci  have  been  found  far  more 
frec|uently  in  hospital  wards  and  operating  amphitheatres  than  else- 
whei'c.  Haegler  found  stajihylococci  and  streptococci  in  the  majority 
of  his  examinations  of  the  air  in  the  wards  antl  operating-rooms  of  the 
hospital  in  Basle,  and  tlie  number  of  such  cocci  present  was  in  general 
proportionate  to  the  opportunity  for  entrance  into  the  air  of  cocci  from 
dry  material  and  to  the  amount  of  stirring  uji  of  dust  by  movement  in 
the  room.  He  also  detected  in  a  number  of  instances  the  bacillus  pyo- 
'  Haegler,  Beiirdge  zur  klinischen  Chirurgie,  Bd.  ix.  p.  496. 


278        GENERAL  BACTERIOLOGY  OF  SURGICAL  INFECTIONS. 

cyaneu.s  in  tlic  air.  Streptococci  have  been  found  frequently  in  the  air 
of  rooms  containing  cases  of  erysipekis. 

Haegler  foiUKl  the  pyogenic  cocci  on  the  hair  antl  coats  of  surgeons, 
and  in  cobwebs  in  hospital  rooms,  as  well  as  on  other  objects.  He  con- 
cludes from  his  investigations  that  the  danger  of  infection  from  (he  air 
is  greater  than  is  assumed  by  many  surgeons. 

Schimmelbusch  and  some  other  investigators  have  found  pyogenic 
cocci  very  rarely  in  surgical  wards  and  operating-rooms.  It  is  suf- 
ficiently apparent  that  various  circumstances,  such  as  the  care  exercised 
in  the  destruction  or  sterilization  of  material  infected  witli  discharges, 
the  use  of  disinfectants,  the  isolation  of  infected  cases,  and  the  observ- 
ance of  strict  cleanliness,  must  influence  the  results  of  these  examina- 
tions of  the  air  of  hospitals,  and  that  tlie  danger  of  air  infection  may  be 
cousideral:)le  in  one  place  and  reduced  to  a  minimum  in  others. 

Air  infection  may  readily  become  contact  infection  by  bacteria  from 
the  air  being  deposited  upon  the  hands  of  the  operator  or  his  assistants, 
upon  instruments,  dressings,  or  other  objects  which  are  brought  into 
contact  with  the  wound. 

jMicro-organisms  which  are  capable  of  develojinient  only  within  the 
living  body  are  called  obligatory  parasites.  A  facultati\'e  parasite  is 
one  whose  or'dinary  mode  of  life  is  .saprojjhytic,  but  which  is  capable 
of  a  parasitic  existence,  and  a  facultative  saprophyte  is  one  whose  ordi- 
nary existence  is  parasitic,  but  which  can  grow  outside  of  a  living  host. 
These  distiuotions,  however,  cannot  always  be  sharply  carried  out  in 
practice.  Although  we  can  cultivate  the  gonococcus  outside  of  the  body 
in  specially  prepared  artificial  media,  there  is  no  reason  to  suppose  that 
it  multiplies,  or  even  long  survives,  in  the  outer  world  under  ordinary 
conditions,  and  immediate  contact  with  the  infected  person  is  the  princijial 
source  of  infection.  The  tubercle  bacillus  also  can  he  cultivated  arti- 
ficially, but  conditions  must  be  excejitional  which  permit  its  nudtiplica- 
tion  outside  of  the  body.  Unlike  the  gonococcus,  the  tubercle  bacillus 
is  capable  of  prolonged  survival  outside  of  the  body,  and,  as  is  well 
known,  it  is  a  widely-distributed  organism.  The  leprosy  bacillus  has 
not  been  cultivated  artificially,  and  it  is  ranked  among  the  obligatory 
parasites.  Intimate  contact  with  an  infected  person  seems  to  lie  the 
usual  source  of  infection,  although  opinions  are  divided  as  to  the  mode 
of  transmission  of  this  disease.  The  micro-organisms  causing  syphilis 
and  hydrophobia  are  unknown,  but  they  are  doubtle.ss  obligatory  para- 
sites. 

The  bacteria  causing  anthrax,  tetanus,  malignant  oedema,  and  actino- 
mycosis are  facultative  parasites.  The  jiyogenic  cocci  find  the  best  con- 
ditions for  their  multiplication  in  the  living  body  or  material  rich  in 
organic  matter,  but  these  ubi(|uitous  bacteria  can  often  find  natural 
opportunity  for  multiplication  outside  of  the  body. 

The  only  bacteria  infectious  for  human  beings  which  are  positively 
known  to  develop  spores  are  the  bacilli  of  tetanus,  anthrax,  and  malig- 
nant oedema,  all  killed  by  exposure  in  a  moist  condition  for  a  few 
minutes  to  boiling  temjieraturc.  It  is  generally  stated  that  the  tubercle 
bacillus  forms  spores,  but  this  is  not  positively  demonstrated.  There  is 
still  greater  doubt  as  to  the  formation  of  spoi'cs  by  the  bacilli  of  gland- 
ers, typhoid  fever,  and  lej)rosy.     The  tubercle  bacillus,  the  pyogenic 


POBTALS  OF  ENTRY  OF  BACTERIA  IN  SURGICAL  INFECTIONS.    279 

cocci,  and  the  typlioid  bacillus  are  among  the  more  resistant  bacteria 
which  are  not  proven  to  form  spores. 

Portals  of  Entry  of  Bacteria  in  Surgical  Infections. 

The  portals  of  entry  or  atria  of  infection  are  the  skin  and  the 
exposed  mucous  membranes  of  tlie  respiratory,  alimentary,  and  genito- 
urinary tract,  and  wounds  of  these  surfaces.  The  fcctus  may  become 
infected  either  by  germinal,  or  far  more  frequently  by  ])lacental,  trans- 
mission of  infectious  micro-organisms.  In  our  lalroratory  experiments 
we  rarely  imitate  the  precise  conditions  of  natural  infection,  but  we 
malce  fre(pient  use  of  methods  of  inoculation  which  occur  only  excep- 
tionally or  not  at  all  under  natural  conditions,  such  as  the  injection  of 
bacteria  directly  into  the  vessels,  into  the  serous  cavities,  and  beneath 
tile  skin,  and  forced  inhalations  of  large  numbers  of  micro-organisms. 

Most  of  the  hatttcria  concerned  in  surgical  infections  are  capable  of 
entrance  tlirougli  any  portal  and  of  pniducing  inl'ection  in  any  part  of 
the  body,  but  there  are  some  which  are  restricted  to  certain  modes  of 
entrance  and  to  certain  parts  of  the  body.  Examples  of  the  latter  group 
are  the  bacteria  causing  gonorrhea  and  tetanus. 

Let  us  consider  briefly  the  defensive  arrangements  which  exist  nor- 
mally at  the  various  pt»rtals  of  entry.  These  are  jiartly  mechanical,  and 
due  to  the  anatomical  structure  of  the  ])art.  The  thick  epidermal  cover- 
ing of  tlie  skin  and  orifices  of  the  body  is  impenetrable  to  most  bacteria. 
The  thick  layer  of  laminated  flat  epitlielium  covering  the  mucous  mem- 
branes of  the  mouth,  esophagus,  and  vagina  is  a  hardly  less  efficient 
mechanical  protection.  The  more  delicate  raucous  membranes  covered 
by  cylindrical  epithelium  are  so  situated  as  to  be  less  exposed  to  injury, 
but  even  tiiese  surfaces  do  not  ordinarily  permit  the  penetration  of  l^ac- 
teria  witiiout  the  occurrence  of  some  damage  to  their  integritv.  The 
ciliated  epitlielium  of  the  respiratory  tract  drives  foreign  particles 
toward  the  natural  outlets.  The  tortuous  arrangement  of  the  upper 
air-passages  filters  out  most  of  the  bacteria  which  are  inhaled.  Bacteria 
which  may  iiappen  to  enter  the  bladder  or  uterus  or  the  glandular  ducts, 
such  as  the  salivary,  Ijiliarv,  or  pancreatic,  which  are  normally  free  from 
bacteria,  would  be  likely  to  be  discliarged  with  the  secretions.  Obstruc- 
tion of  these  ducts  predisposes  to  their  infection. 

There  are  certain  situations,  particularly  the  tonsils  and  the  lymphatic 
follicles  of  the  intestine,  M'liich,  by  the  delicate  nature  of  their  covering, 
are  especially  exposed  to  tlie  invasion  of  bacteria.  These  are  vulnerable 
parts,  as  is  sliown  Iiy  the  frecpiency  with  which  primary  and  secondary 
infections  start  froui  them,  but  there  is  reason  to  believe  that  the  Ivm- 
phatic  tissue  in  these  situatioi.s  is  richly  endowed  with  vital  jirojierties 
hostile  to  the  development  of  bacteria. 

Of  equal  importance  with  these  mechanical  defences  arc  the  anti- 
bacterial properties  of  the  secretions  on  mucous  membranes.  These 
properties  depend  partly  on  the  chemical  reaction  (gastric  juice,  vaginal 
secretion),  jiartly  on  the  antagonism  offered  to  invaders  bv  the  regular 
bacterial  flora  of  the  surface,  but  mainly  upon  bactericidal  qualities  at 
present  little  understood  as  to  their  cause,  but  unquestionable  as  to  their 
existence. 


280       GENERAL  BACTERIOLOCrY  OF  SURGICAL  INFECTIONS. 

Mi('ro-()i-i;aiiisins  find  at  tlie  fratos  of  entrance  livin<>-  cells  and  fluids 
which  in  healtJi  are  capable  of  destroying  many  of  them,  and  if  thcv 
pass  these  gates,  it  is  usually  only  to  be  arrested  and  destroyeil  at  the 
nearest  lymphatic  glands.  Xor  are  these  j)rotective  agenci(>s"liniited  to 
the  lymi)hatics  or  to  any  jiarticular  organs  :  they  are  present  in  the  blood 
and  everywhere  througjiout  tiie  living  body,  altliougli  more  highly  devel- 
oped in  some  places  than  in  others.  Whether  the  battle  against  the 
invaders  be  within  the  cells,  as  is  assumed  in  the  phagocytic  theory,  or 
outside  of  the  cells,  the  weapons  of  attack  must  be  furnished  bv"  the 
cells.  The  living  body  is  amply  protected  in  health  against  all  ordinary 
bacteria  which  may  seek  entrance,  and  the  study  of  the  etiologv  of  infec- 
tious diseases  involves  the  consideration  not  oidy  (if  the  characters  of  the 
specific  agents  of  infection,  but  also  of  the  ways  in  which  the  natural 
defences  of  the  body  have  been  overcome.  There  are  infectious  micro- 
organisms to  which  the  healthiest  and  strongest  body  is  able  to  offer  no 
resistance,  and  there  are  other  micro-organisms  which  are  I'ajiable  of 
doing  harm  only  -h  hen  tlie  vital  resistance  of  the  body  has  liecn  lowered. 

Can  micro-organisms  penetrate  the  intact  skin  or  mucous  membranes, 
or  must  there  always  be  some  jtathological  change  or  lesion  of  continuity 
of  these  parts  to  permit  their  entrance  ?  This  question  has  been  variously 
answered,  but,  at  least  as  for  as  certain  membranes  and  certain  micro- 
organisms are  eoncerned,  the  evidence  must  be  regarded  as  conclusive 
for  the  affirmative  answer.  It  cannot  be  doubted  that  the  infectious 
agents  causing  malaria,  relapsing  fever,  and  the  eruptive  fevers  may 
enter  tlie  body  without  any  defect  in  the  skin  or  mucous  membranes, 
but  our  concern  is  not  with  this  class  of  diseases. 

Garre,'  in  1885,  was  the  first  to  make  a  self-sacrificing  experiment 
which  has  since  been  rejieated  \\ith  similar  result  In'  several  others.  He 
rubbed  into  the  skin  of  his  fu-earm,  in  the  same  way  as  one  \\-ould  rub 
in  an  ointment,  a  large  quantity  of  a  virulent  culture  of  the  staphylo- 
coccus pyogenes  aureus.  The  skin  was  left  intact.  After  six  hours  a 
prickling  sensation,  associated  ^ith  redness  and  turgescence,  developed, 
and  in  a  few  hours  more  about  twenty  pustules,  each  developing  about 
a  laimgo  hair,  had  formed.  In  the  course  of  four  days  an  extensive 
carbuncle,  which  discharged  pus  through  seventeen  openings,  formed, 
and  the  axillary  glands  were  swollen. 

The  largest  numlicr  of  experiments  of  this  character  have  been  by 
Wasmuth.^  The  experiment  succeeds  almost  invariably  when  virulent 
staphylococci  are  thoroughly  rubbed  into  the  human  skin,  but  fails 
almost  constantly  to  give  a  positive  result  ujion  the  skin  of  animals 
(rabbits,  guinea-pigs).  The  failure  with  animals  is  not  due  to  greater 
impenetrability  of  their  skin  to  bacteria,  for  anthrax  bacilli  and  some 
other  pathogenic  bacteria  when  rubbed  into  the  skin  of  animals  are 
capable  of  causing  infection.  Animals  are  less  susceptible  than  man  to 
these  pyogenic  cocci — a  fact  which  should  not  be  lost  sight  of  in  draM'- 
ing  inferences  applicable  to  man  from  experiments  upon  animals  with 
these  organisms.  Biidinger  has  shown  that  pyogenic  cocci  nearly  devoid 
of  virulence  for  animals  may  produce  abscesses  when  rubbed  into  the 
human  skin. 

'  GaiT^,  Forlxchrilk  der  3fedicin,  Bd.  iii.  p.  165,  1885. 

2  Wasmuth,  Ccntnilblalt  fiir  Bacleriohyie,  Bd.  xii.  pp.  824  and  846,  1892. 


PORTALS  OF  EXTRY  OF  BACTERIA  IN  SURGICAL  IXFECTIOyS.    281 

The  mere  application  of  tlie  ijaeteria  to  the  siirflice  of  tlie  skin  i)ro- 
duccs  no  infection  either  in  man  or  animal^;.  The  bacteria  must  be  well 
rubbed  in  or  pressed  in  to  cause  infection. 

Throuiiii  wiiat  channels  do  the  bacteria  penetrate  the  skin  in  these 
experiments?  There  are  tlu'ce  possil)ilities — namely,  through  the  epi- 
dermis into  the  rete  Malpighii,  into  tiie  sweat-glands,  or  into  the  hair- 
follicles  and  sebaceous  glands,  yciununelbuscli,  Machnoif,  and  Wasnnith 
have  demonstrated  that  they  enter  by  way  of  the  hair-follicles,  and  the 
last-named  author  considers  that  they  can  enter  the  intact  skin  in  no 
other  way.  He  finds  a  principal  support  for  this  view  in  the  fact  that 
he  was  unable  to  produce  any  effect  l)y  rubbing  the  cultures  into  the  skin 
of  the  ball  of  the  thuml),  where  there  are  no  hair-follicles,  and  in  the 
actual  demonstration  liv  himself  and  previous  experimenters  of  the  bac- 
teria in  the  hair-follicles.  This  conclusion  is  in  accord  witli  the  clinical 
fact  that  furuncles  form  almost  exclusively  in  parts  of  the  skin  provided 
with  hairs  and  sebaceous  glands,  and  often  begin  as  pustules  around  the 
hairs. 

The  ol)jection  mav  be  raised  that  these  ex])eriments  do  not  actually 
prove  the  possibility  of  infectious  agents  penetrating  the  intact  skin,  as 
microscopical  lesions  may  be  caused  by  tlie  rubbing  or  the  }3ressure. 
Macroscopical  and  microscopical  examinations,  however,  failed  to  show 
any  lesion  of  the  epidermis.  Still,  a  microscopical  defect  might  be  diffi- 
cult to  detect,  and  Schimmelbusch  considers  it  possible  that  in  these 
experiments  a  minute  Ijreach  of  continuity  may  be  produced. 

As  experiments  uj)on  rabbits  with  bacilli  of  anthrax  and  of  rabliit 
septictemia  have  shown,  general  as  well  as  local  infection  may  follow  the 
rubbing  of  certain  pathogenic  bacteria  into  the  skin.  These  experiments 
simplv  show  that  certain  pathogenic  organisms  are  capable  of  settling  in 
the  iiealthy  skin  and  causing  local  infections,  which  may,  however,  be 
the  starting-point  of  general  infections.  They  do  not  show  that  micro- 
organisms can  pass  through  the  healthy  skin  and  thence  invade  the  body 
witliont  jiroducing  any  damage  at  the  point  of  entrance.  It  is  a  well- 
known  clinical  fact  that  in  wounds  this  local  damage  may  be  very  slight 
and  readily  overlooked.  Indeed,  there  is  a  certain  antagonism  between 
the  extent  of  the  local  infection  at  the  point  of  invasion  and  the  likeli- 
hood of  general  infection. 

We  have  no  conclusive  experimental  evidence  that  bacteria  can  enter 
the  circulation  through  an  intact  mucous  membrane  without  causing  any 
lesion  whatever  at  their  point  of  entry.  There  are,  however,  many  ex- 
amples of  ]iathogenic  bacteria  which  are  cajmble  of  attacking  a  healthy 
nuu'ous  membrane  and  of  ])roducing  local  and  general  infection  through 
this  cluuMiei.  The  lesion  of  tlie  mucous  membrane  in  some  of  these  cases 
maybe  slight  and  not.  readily  demonstrable.  The  gonococcus  is  certainly 
capable  of  infecting  an  intact  mucous  membrane.  A  large  number  of 
infectious  diseases  can  be  produced  by  feeding  cultures  or  material  con- 
taining certain  pathogenic  bacteria.  Examples  of  such  intestinal  infec- 
tions are  tuberculosis,  anthrax,  typhoid  fever,  Asiatic  cholera,  hog  cholei'a, 
and  chicken  cholera.  As  has  already  been  mentioned,  the  points  in  the 
alimentarv  canal  most  vulnerable  to  infection  are  tlie  tonsils  and  the 
lymphatic  follicles. 

As  is  well  known,  indifferent  foreign  particles,  such  as  coal-dust,  may 


282       GENERAL  BACTERIOLOGY  OF  SURGICAL  INFECTIONS. 

be  taken  up  from  tlie  air-cells  ni'  tlie  liiiijis  and  eonveycd  by  the  lymphatic 
current  to  the  broneliial  lym])liatie  liiands,  but  under  normal  conditions 
these  ])artieles  do  not  enter  tlie  ti'eneral  cireulation.  It  is  ])robable  that 
bacteria  maybe  disjiosed  of  in  tlie  same  way.  It  is  said  that  some  of  tlie 
bacteria  of  the  septicsemias  of  animals — as,  for  example,  the  bacillus  of 
rabbit  septicaemia — may  enter  the  circulation  through  the  lungs  without 
leaving  behind  any  manifest  lesion.  We  have  no  conclusive  evidence 
that  the  mieroeoeeus  lanceolatiis,  the  streptococcus  pyogenes,  or  the  other 
pyogenic  bacteria  can  ])ass  through  the  intact  lungs  into  the  general  cir- 
culation without  causing  some  intlammation  of  the  lungs. 

The  lungs  possess  the  power  of  disposing  of  many  pathogenic  bacteria 
which  have  been  introduced  into  tiiem.  There  have  been  many  experi- 
ments made  to  determine  the  ]M)Ssibility  of  infection  with  anthrax  bacilli 
bv  way  of  the  lungs,  and  the  conclusions  drawn  from  them  hav(>  been 
wi<lelv  divergent.  Buehner  and  his  (inpils  claim  to  have  succeeded,  but 
Baumgartcn  and  his  co-workers  reached  a  ditferent  conclusion,  (irainat- 
schikoti'  finds  that  the  intratraciieal  injection  of  anthrax  bacilli  or  spores 
is  incapable  of  causing  infection  if  infection  through  the  wound  be 
avoided.  The  bacilli  quickly  perished  in  the  lungs,  sections  showing 
degenerated  Ijacilli  within  four  to  ten  hours. 

No  infection  of  an  intact  mucous  membrane,  either  in  man  or  animals, 
has  been  produced  experimentally  l)v  the  mere  application  to  the  surface 
of  the  membrane  of  the  pyogenic  cocci,  altliough  thei'c  is  clinical  evidence 
of  the  possibility  of  such  a  mode  of  infection. 

The  chief  surgical  interest  of  the  cpiestion  of  the  permeability  of  intact 
mucous  membranes  to  bacteria  relates  to  the  explanation  of  tuberculosis 
of  internal  parts  without  tubercular  lesion  at  any  portal  of  entry,  and  to 
cases  of  osteomyelitis,  internal  abscesses,  and,  in  general,  the  cases  of  so- 
called  cryptogenetic  septicaemia  and  jjysemia,  in  which  the  most  careful 
examination  fails  to  detect  any  point  where  the  bacteria  could  have 
entered. 

Most  authorities  are  of  the  opinion  that  tubercle  bacilli  can  pass 
through  a  mucous  surface  without  leaving  any  trace  liehind  of  their 
presence  at  the  point  of  entrance.  The  main  support  for  this  doctrine 
of  the  passage  of  tubercle  bacilli  through  intact  mucous  membranes  is 
found  in  the  clinical  facts.  Orth  and  Wesencr,  however,  claim  that 
occasionally  animals  fed  with  tubercle  bacilli  develop  tuberculosis  of  the 
mesenteric  glands  without  any  tubercular  alteration  of  the  intestinal  mu- 
cous membrane.  Baumgartcn  contests  this,  and  holds  that  in  all  cases 
of  experimental  tuberculosis  there  is  a  tuberculous  lesion  at  the  point  of 
entry.  He  explains  the  cases  of  tuberculosis  of  lymphatic  glands,  of 
bone,  and  of  other  parts  observed  not  infrequently  in  man  without 
tuberculosis  of  the  lungs  or  any  exposed  surface  by  assuming  that  they 
are  all  instances  of  inheritance  of  tubercle  bacilli.  This  well-known 
doctrine  of  Baumgartcn  involves  also  the  assumption  that  tubercle  bacilli 
mav  remain  for  an  indefinite  time  alive  within  the  body  in  a  latent  con- 
dition. 

In  the  opinion  of  the  writer  the  evidence  is  in  favor  of  the  view  that 
tubercle  bacilli  may  enter  the  lym))hatic  circulation  without  causing  any 
tuberculous  aifection  at  the  ])oint  of  entrance.  In  many  cases,  however, 
where  this  exjjlanation  might  at  first  be  thought  to  be  the  correct  one, 


PORTALS  OF  ENTRY  OF  BACTERIA  IN  SURGICAL  INFECTIONS.    283 

careful  seai'ch  will  reveal  the  atrium  morbi,  not  infrequently  in  the 
form  of  a  small  healed  tuberculous  focus  in  the  lungs  or  other  exposed 
part.  H.  P.  Loomis  has  found  tubercle  bacilli  in  the  bronchial  glands 
with(iut  tul)erculous  lesion  in  any  part  of  the  body. 

It  is  not  possil)le  at  present  either  to  prove  or  to  disprove,  for  man, 
the  possibility  of  the  passage  tiirougli  an  intact  mucous  membrane  of 
the  pyogenic  cocci,  whicli  are  the  organisms  usually  concerned  in  the 
so-called  ervptogenetic  pytemic  and  septic  processes.  It  is  true  that  the 
most  careful  examination  in  many  of  these  cases  fails  to  reveal  the  atrium 
of  infection,  but  wlio  can  say  that  it  may  not  have  been  overlooked? 
The  more  painstaking  the  search,  the  more  likely  is  some  portal  of  entry 
to  l)e  found.  Tliis  portal  may  be  the  root  of  a  carious  tootii,  the  middle 
ear,  one  of  the  nasal  sinuses,  or  some  other  j)art  not  usually  examined 
at  autopsies.  Who  can  feel  sure  that  in  the  whole  vast  extent  of  tiie 
alimentary,  respiratory,  or  genito-urinary  mucous  membranes  some 
minute  lesion,  serving  as  a  point  of  entry,  does  not  exist?  Sucii  a  lesion 
may  be  microseopic  in  size,  perliaps  no  more  than  a  necrotic  epitlielial 
cell.  Moreover,  we  have  to  consider  that  the  original  lesion  at  the  point 
of  entry  may  have  healed  without  leaving  any  recognizable  trace ;  nor 
need  this  lesion  be  a  recent  one.  There  are  instances  of  fatal  septiciemia 
following  mere  punctures  and  scratches  of  the  skin  which  gave  rise  to 
.scaiwly  any  local  intlamniation,  and  the  septicaemia  may  develop  after 
the  point  of  original  injury  lias  healed  and  been  forgotten.  Bacteria, 
including  pathogenic  species,  may  n^main  alive,  but  (juiescent,  for  weeks 
and  months,  in  some  instances  it  W(Kild  seem  even  for  years,  within  the 
body,  and  tiien,  as  the  result  of  a  trauma  or  some  other  cause,  their 
pathogenic  energies  may  be  stimulated  into  activity. 

A\'hile  it  is  certain  that  in  many  instances  pathogenic  micro-organisms 
may  invade  an  intact  mucous  membrane  and  cause  local  and  general 
infection,  and  tliat  in  some  instances  the  organism  may  enter  the  circula- 
tion and  be  transported  to  distant  parts  without  manifest  lesion  at  the 
point  of  entrance,  and  while  the  possibility  of  the  latter  occurrence  can- 
not lie  disjiroven  in  the  case  of  tiie  pyogenic  cocci,  nevertheless  there 
can  be  no  doubt  that  pathological  alterations  and  wounds  of  tiie  exposed 
surfaces  of  the  body  open  the  way  for  the  entrance  of  the  pathogenic 
micro-organisms  in  most  surgical  infections.  For  some  pathogenic  organ- 
isms, including  pyogenic  cocci  of  exalted  virulence — such  as  may  come 
from  a  case  of  puerperal  peritonitis,  for  example — all  that  is  needed  is 
that  the  parts  siiould  be  thus  opened,  and  infection  is  sure  to  follow  tiieir 
entrance.  But  we  JKne  only  to  contrast  the  frequency  with  wliich 
streptococcus  and  other  pyogenic  infections  complicate  or  follow  the 
infectious  fevers,  such  as  ty])iioid,  characterized  by  lesions  of  nuicous 
membranes,  or  tlie '  frequency  witii  wliich  infection  follows  external 
wounds  in  diabetic  and  dropsical  persons,  with  the  rarity  of  such  a  sequel 
to  injuries  of  the  same  parts  in  a  healthy  person,  to  appreciate  the 
importance  of  other  factors  than  tlie  mere  breach  of  continuity  in  an 
exposed  surface  in  predisposing  to  local  and  general  infections.  We 
shall  consider  later  these  local  and  predisjiosing  causes  of  surgical 
infections. 

Interesting  experiments  have  been  made  by  Schiinmelbuseh,  Nissen, 
Pfulil,  and  others  as  to  the  rapidity  of  absorption  of  bacteria  from  fresh 


284        GENERAL   liACTh'n/O/JjaV   OF  SUHCICAr.   IM'KCTIoys. 

womids.  They  liavo  demonstrated  tliut  bacteria  are  taken  np  witliin 
a  very  short  time,  by  the  lymphatic  and  blood-vessels,  t'rom  a  fresh 
blcedinir  wound.  Mice  inoculated  witli  anthrax  l)acilli  at  the  tip  of 
the  tail  died  of  anthrax  in  si>ite  of  amputation  of  tiic  tail  ten  mimites 
after  the  inocnlation.  Nissen  found  anthrax  bacilli  in  the  neai-est  Ivm- 
phatic  glands  within  one  hour  and  a  half  after  peripheral  inoculation 
of  an  extremity.  The  application  to  smooth  fresh  wounds  by  Schini- 
mclbusch  of  a  moderate  tjuantity  of  a  culture  of  the  anthrax  bacillus 
or  of  a  streptococcus  lethal  to  mice  was  fatal,  notwithstandinii-  an  innne- 
diate  attempt  at  disinfection  of  the  wonnd  witii  the  strongest  antiseptics, 
ychimmclbusch  and  IJicUer'  were  able  to  demonstrate  in  cultures  from 
tiie  internal  organs  (lung,  liver,  spleen,  kidney)  anthrax  bacilli  in  an 
hour,  or  even  half  an  hour,  after  the  incjculation  of  fresh  wounds  of 
mice  with  this  organism.  They  showed  that  this  rapid  absorption  of 
bacteria  from  fresh  bleeding  wounds  applies  equally  to  pathogenic  and 
sa]n-o])hytic  bacteria.  In  cultures  from  the  internal  organs  mad(>  five 
mimites  after  the  infection  of  a  fresh  wound  of  a  rabbit's  thigh  with  the 
bacillus  jjyocyancus  they  found  many  colonies  of  this  bacillus.  In 
making  the  cultures  it  is  necessary  to  use  the  whole  organ  finely 
divided. 

The  significance  for  the  individual  of  the  rapid  absor])tion  of  bacteria 
from  fresh  wounds  depends,  of  course,  primarily,  uixm  the  character  of 
the  bacteria.  If  these  in  small  or  moderate  number  are  cajjablc  of 
causing  fatal  septicemia,  as  is  the  case  with  virulent  anthrax  bacilli  in 
highly  susceptible  animals,  the  issue  is  necessarily  fatal ;  if,  as  is  the 
case  with  the  pyogenic  cocci,  the  bacteria  do  not  readily  gain  a  foothold 
where  they  can  multiply,  their  absorption  is  of  little  consequence  in 
most  cases,  and,  so  far  as  the  ordinary  saprojihytes  are  concerned,  their 
aljsorption  from  fresh  wounds  is  a  matter  of  indifference. 

The  period  during  which  this  rapid  absorption  of  bacteria  from 
a  fresh  wound  takes  place  is  of  short  duration.  As  soon  as  a  coagulum 
has  formed  on  the  surface  of  the  wound  and  the  open  mouths  of  the 
lymjihatic  and  blood-vessels  are  plugged,  the  conditions  are  changed, 
and  fine  particles  like  bacteria  are  no  longer  (piickly  transported  into  the 
lymj)hatic  and  blood  circulation.  The  surface  of  a  healthv  granulating 
wound  ofiiers  great  resistance  to  the  invasion  of  bacteria,  almost  as  nuich 
as  an  intact  exposed  surface  of  the  body.  Slight  injuries,  however,  such 
as  probing,  the  removal  of  dressings,  and  other  manipulations,  may  con- 
vert a  granulating  surface  into  a  fresh  wound,  with  the  accompanying 
dangers  of  infection. 

Elimination  of  Bacteria  in  the  Secretions. 

In  former  times  it  M'as  thought  that  the  body  gets  rid  of  infectious 
agents  chiefly  by  their  excretion  through  the  eniunctory  channels.  We 
now  know  that  micro-organisms  ai'e  destroyed  within  the  body  by  the 
living  cells  and  fluids,  and  that  this  method  of  freeing  the  Ixidy  from 
living  bacteria  is  far  more  efficient  and  of  much  greater  importance  than 
that  of  their  excretion  by  the  cmiuictorics. 

Pathogenic  bacteria  often  appear  in  the  secretions  in  various  infectious 

'  Schimmelbusch,  Deutsche  med.  Wochemchrift,  July  12,  1894. 


ELIMINATION  OF  BACTERIA   IN  THE  SECRETIONS.  285 

diseases,  and  it  is  of  interest  to  know  under  what  conditions  they  are 
excreted  and  in  what  secretions  they  occur.  The  mode  of  conveyance 
of  infectious  organisms  from  an  infected  individual  to  others,  and  the 
practical  measures  of  prevention,  are  determined  in  large  measure  by  tlie 
manner  of  elimination  of  these  organisms  from  the  infected  body. 

Wyssokowitsch,  as  the  result  of  a  long  series  of  experiments,  came  to 
the  conclusion  that  bacteria  in  the  circulation  are  never  discharged  from 
the  body  through  the  healthy  organs,  but  escape  only  through  some 
breach  df  continuity  or  other  lesion  in  the  excretory  membrane.  Hence 
those  pathogenic  bacteria  which  cause  some  damage  to  the  excretory 
surflices — and  there  are  many  such  bacteria — arc  most  likely  to  appear  iu 
the  excreta,  although  bacteria  without  this  capacity  may  escajjc  through 
lesions  preforuied  from  other  causes. 

Not  all  subsequent  investigators  of  this  subject  have  been  able  to  con- 
firm this  law  of  Wyssokowitsch,  aud  it  is  true  tliat  l)actcria  may  be  elimi- 
nated from  the  circulation  Ity  way  of  tiic  excretions  without  demonstral>le 
lesion  of  the  organ  tlirough  whicli  they  liave  passed.  It  is  to  be  remem- 
bered, however,  that  the  lesion  may  be  difficult  to  detect,  or  may  be  of 
some  such  undemonstrable  character  as  that  of  the  vascular  walls  in 
inflammation  which  permits  the  passage  of  leucocytes  and  red  blood- 
corpuscles. 

There  ha\-e  been  many  special  and  incidental  investigations  of  the 
subject  of  the  escape  of  bacteria  ^vith  the  secretions.  Of  the  experimental 
investigations  relating  to  the  subject  in  general  the  most  important  are 
those  of  Wyssokowitsch,  Pernice  and  Scagliosi,  and  Sherrington.' 

Sherrington  experimented  on  mice,  rabbits,  and  guinea-pigs  by  the 
subcutaneous  or  intravenous  iuoculation  of  eleven,  mostly  pathogenic, 
species  of  bacteria.  In  sixty-eight  observations  the  presence  of  the 
.specific  micro-organisui  introduced  was  detected  in  the  urine  twenty- 
one  times ;  on  eight  of  these  twenty-one  occasions  the  presence  of  blood 
in  the  urine  was  ascertained  by  the  spectroscope ;  and  in  a  ninth  case 
gross  lesions  (tubercle)  were  found  in  the  kidney.  Sometimes  the  urine 
contained  much  coagulable  albumin.  Of  the  bacteria  of  surgical  im- 
jjortance  tested,  tlie  stapliylococcus  aureus,  the  bacillus  pyocyaneus,  the 
bacillus  anthracis,  and  a  bacillus  jirobaljly  identical  with  the  Friedliinder 
bacillus  were  found  frccpicutly  in  the  urine.  In  Ibrty-nino  experiments 
the  specific  bacilli  were  found  in  the  bile  in  eighteen.  The  bacillus  of 
mouse  septicremia  appeared  in  the  conjunctiva,  which  became  inflamed, 
under  conditions  making  it  probable  that  it  did  not  enter  from  without. 
Among  the  points  especially  emphasized  by  Slierrington  are  tlie  fol- 
lowing : 

"At  a  time  when  every  drop  of  the  circulating  blood  is  teeming  with 
micro-organisms  there  may  not  be  the  slightest  transit  of  them  into  the 
urinary  and  biliary  fluids  then  secreted,  and  they  may  be  completely 
absent  from  the  aqueous  humor  of  the  eye-ball." 

"When  certain  pathogenic  s]iccies  are  employed,  a  number,  often 
very  consideral)lc,  of  tlie  injected  bacteria  tend  after  a  time  to  appear  in 
the  secretions  of  the  kidney  and  liver,  and  their  escape  in  the  secreta  is 

'  Sherrington,  "  Experiments  on  tlie  Escape  of  Bacteria  with  the  Secretions,"  The 
Joui-nal  nf  PalhtiUnjtj  and  Bacteriology,  Feb.,  1893.  This  vahiable  article  contains  a  full 
review  of  the  literature. 


286       GENERAL  BACTERIOLOGY  OF  SURGICAL  INFECTIONS. 

sometimes  accompanied  by  an  escape  of  actual  blood,"  although  not  infre- 
(juently  there  is  no  blood  in  the  secreta. 

"  The  evidence  is  aoainst  believing-  tiiat  when  this  transit  of  bacteria 
across  the  sccretinii;  nienihrane  occurs  tiie  membrane  is  still  normal  in 
condition,  althougiiat  the  same  time  it  need  not  be  ruptured  or  pervious 
to  red  blood-corpuscles." 

"  The  fact  that  the  escape  of  the  bacteria  tends  to  occur,  not  immedi- 
ately upon  the  introduction  of  them  wholesale  into  the  circulation,  but 
in  the  late  stages  of  the  communicated  disease,  suggests  that  tiie  healthy 
secreting  membranes  arc  not  pervious  to  bacteria,  and  that  only  after 
soluble  jioisons  j)roduced  by  the  infection  have  had  time  to  act  upon 
them  do  the  membranes  became  pervious  to  tlie  germs.  The  fact  that 
species  which  are  innocuous  did  not  in  the  experiments  appear  in  tiie 
secreta  at  any  time  is  in  conformity  with  this  conclusion." 

Pernice  and  iScagliosi  experimented  with  stapiiylococcus  aureus, 
bacillus  prodigiosus,  bacillus  anthracis,  bacillus  pyticyaneus,  and  liacillus 
subtilis,  and  they  found  that  these  bacteria  were  constantly  excreted 
through  the  urine  and  bile,  and  might  escape  through  various  mucous 
membranes.  This  excretion  begins  six  to  eight  hours  after  their  inti'o- 
duction.  Virulent  bacteria  retain  their  virulence,  as  a  rule,  in  the 
excreta. 

There  are  numerous  observations  in  human  beings  of  the  escape  of 
infectious  bacteria  tin-ough  tiie  excretions.  The  pyogenic  cocci  are  par- 
ticularly prone  to  settle  in  the  kidney  and  cause  focal  inflammations,  but 
even  witiiout  actual  foci  of  suppuration  they  often  escape  into  tlie  urine. 
Xannotti  and  Baciochi,  Ijoth  in  grave  suppurative  processes  and  in  slight 
ones,  foimd  the  specific  bacteria  ■with  great  frequency  and  of  customary 
virulence  in  the  uriiK'.  They  disapjieared  from  the  urine  t^^■cnty-four  to 
tiiirty-six  hours  after  tlie  evacuation  of  the  pus.  In  experimental  pyo- 
cyaneus  infections  the  specific  bacillus  is  found  regularly  in  the  urine. 
The  micrococcus  lanceolatus  in  pneumonia  and  other  pnenmococcus 
infections,  the  tvj)hoid  bacillus  in  typhoid  fever,  the  streptococci  in 
erysipelas  and  other  streptococcus  infections,  are  often  present  in  the 
urine.  The  bacillus  coli  communis,  tlie  most  common  of  all  secondary 
invaders,  often  escapes  through  the  kidney. 

Pathogenic  bacteria  are  eliminated  very  often  through  the  bile.  One 
of  the  most  common  lesions  in  various  infectious  diseases  is  the  presence 
of  focal  necroses,  sometimes  visible  to  the  naked  eye  and  sometimes  seen 
only  with  the  microscope,  in  tiie  liver,  and  these  jiermit  the  passage  of 
bacteria  into  the  bile.  It  is  not,  however,  necessary  that  such  necroses 
should  be  present  in  order  to  permit  tlie  escape  of  bacteria  into  the 
bile. 

Blachstein,  in  experiments  made  under  the  direction  of  the  writer,^ 
demonstrated  that  the  colon  bacillus  and  the  typhoid  bacillus  injected 
into  the  veins  of  rabbits  often  aji])eared  in  the  bile,  ^\•llere  they  frc(|uently 
remained  alive  and  in  large  number  wcel^s  and  months  after  they  had 
disappeared  from  all  of  the  internal  organs.  In  many  of  these  cases 
there  were  focal  necroses  in  the  liver.  The  passage  from  the  circulation 
into  the  bile  of  the  anthrax  bacillns,  of  the  micrococcus  lanceolatus,  the 
streptococcus  pyogenes,  the  pyogenic  stajihylococci,  the  bacillus  pyocya- 
ueus,  and  of  other  bacteria  has  been  repeatedly  demonstrated.     Patho- 


ELIMINATION  OF  BACTERIA  IN  THE  SECRETIONS.  287 

gcnic  bacteria  arc  quite  as  frequently  discharged  through  the  bile  as 
through  the  urine. 

Of  course  bacteria  iu  the  bile  will  enter  the  intestine  with  this  secre- 
tion, and  it  is  therefore  not  always  easy  to  determine  whether  specific 
pathogenic  bacteria  found  in  the  intestine  in  infectious  diseases  have 
been  discharged  through  the  wall  of  the  intestine  or  through  the  liver. 
]\Iost  of  the  observations  recorded  concerning  the  transit  of  bacteria 
through  the  intestinal  wall  from  the  circulation  have  not  been  made  so 
as  to  determine  whether  or  not  the  escape  is  really  through  the  intestinal 
mucosa  or  by  way  of  the  bile.  Nevertheless,  the  frequency  with  which 
hemorrhages,  necroses,  inflanunations,  and  ulcers  of  the  hitestinal  nuicous 
membrane  occur  in  various  infectious  diseases  makes  it  highly  probable 
that  pathogenic  bacteria  may  be  eliminated  through  this  channel.  Cer- 
tain it  is  that  the  specific  infectious  bacteria,  not  only  of  diseases  like 
typhoid  fever,  cholera,  and  tuberculosis,  characterized  by  definite  intes- 
tinal lesions,  but  of  many  other  diseases,  such  as  croupous  pneumonia, 
septieiemia,  py;emia,  are  often  found  in  the  ffpces. 

Tuljercle  l)acilli  may  be  present  in  the  milk  of  tnljcrculous  cows  even 
when  there  is  no  demonstrable  tuberculosis  of  the  udder.  The  state- 
ments as  to  the  frequency  of  this  occurrence  vary.  Ernst  demonstrated 
by  the  microscope  tubercle  bacilli  in  the  milk  of  28.5  per  cent,  of  the 
thirty-five  tuberculous  cows  examined,  and  by  in(jculation  experiments 
in  50  per  cent,  of  fourteen  cows.  Bang  by  the  inot'ulation  test  found 
tubercle  bacilli  in  the  milk  of  only  nine  out  of  sixty-three  tuberculous 
cows  without  mammary  tuberculosis.  When  the  udder  is  tuberculous 
the  bacilli  are  always  in  the  milk. 

Numerous  observations  have  been  made  to  determine  whether  or  not 
the  pyogenic  cocci  are  excreted  with  the  milk  in  puerperal  infections, 
but  since  we  now  know  that  the  stajihylococcus  albus  is  regularly,  and 
the  staphylococcus  aureus  is  sometimes,  present  in  the  milk  of  healthy 
women,  the  demonstration  of  these  cocci  in  the  milk  in  eases  of  puer- 
peral fever  has  lost  much  of  its  diagnostic  significance.  There  is, 
however,  reason  to  believe  that,  although  the  ordinary  source  of  the 
staphylococci  found  in  the  milk  is  from  the  skin,  they  may  be  excreted 
through  the  gland  from  the  blood  in  pyogenics  infections.  The 
presence  of  streptococci  in  the  milk  is  more  significant  of  such  ex- 
cretion than  that  of  staphylococi'i.  In  several  cases  of  puerjieral 
fever  streptococci  have  been  found  in  the  milk,  although  more  fre- 
quently they  are  missed  in  this  secretion  under  these  circumstances. 
There  is  evidence  that  the  ]iyogenic  cocci  causing  mastitis  may  enter 
either  from  without  through  the  lacteal  ducts  or  may  have  been  depos- 
ited from  the  circulating  blood.  Karlinski  claims  to  have  demonstrated 
that  the  staphylococcus  aureus  injected  into  the  blood  of  rabbits  mav  be 
excreted  through  the  mammary  gland. 

Foil  and  Bordoni-Ulfreduzzi  and  Bozzolo  have  found  pneumococci  in 
the  milk  of  pregnant  women  affected  with  lobar  pneumonia,  and  the 
former  investigators  demonstrated  their  presence  in  the  milk  of  preg- 
nant rabbits  inoculated  with  this  organism,  and  noted  j)neumococcus 
septicicmia  in  young  rabbits  which  sucked  the  breast  of  their  infected 
mothers. 

The  typhoid  bacillus  has  been  fi)inid  exceptionally  in  the  milk  in  cases 


288       GENERAL  BACTERTOLOGY  OF  SURGICAL  INFECTIOyS. 

of  typhoid  fever.  In  ex]icriin(iital  imtlirax  the  specific  bacillus  appears 
in  the  milk  only  exoe|)tionally. 

Brunner  found  the  staphylococcus  all)us,  von  Eiselsber<j,  Preto,  and 
Tizzoni  the  staphylococcus  aureus,  in  the  sweat  in  cases  of  ])yiuniia.  The 
detection  of  staphylococci,  particularly  of  the  stajjhylococcus  albus,  in 
the  human  sweat  does  not  necessarily  prove  that  they  have  been  excreted 
throup^h  the  sweat-glands  from  the  1)1o(k1,  for  even  after  the  most  thor- 
ough  disinfection  of  the  surface  of  tiie  skin  the  white  staphylococcus  has 
not  usually  been  destroyed  in  the  deeper  layers,  as  has  already  been 
explained  in  describing  the  bacteria  of  the  skin.  Still,  it  is  ])rol)al)le 
that  pyogenic  cocci  may  be  eliminated  by  the  sweat-glands,  for  Erunner 
has  shown  that  the  staphylococcus  aureus  and  the  bacillus  prodigiosus 
injected  into  the  circulation  of  swine  can  be  demonstrated  in  the  sweat 
from  the  snout  after  administration  of  pilocarpine.  He  was  also  able  to 
detect  the  anthrax  Itacillus  in  the  sweat  from  the  paw  of  an  infected  cat 
after  stimulation  of  the  sciatic  nerve.  He  reports  only  three  experiments, 
and  it  is  desirable  that  more  work  should  be  done  on  this  subject,  as  the 
frequency  with  which  pathogenic  bacteria  may  appear  in  the  sweat  in 
infectious  diseases  is  of  imjiortance,  especially  with  reference  to  possibil- 
ities of  contagion  and  to  measures  of  disinfection. 

In  Brunner's  experiment  with  the  bacillus  prodigiosus  this  organism 
was  found  also  in  the  saliva,  and  there  are  other  observations  whicii  indi- 
cate the  possibility  of  elimination  of  bacteria  through  the  salivary  glands. 

Conditions  favoring  the  Development  of  Surgical  Infections. 

There  ai-e  various  conditions,  relating  partly  to  the  micro-organisms 
concerned  and  partly  to  the  individual  receiving  the  organisms,  which 
are  determining  factors  in  causing  infection.  The  factors  pertaining 
to  the  individual  are  usually  grouped  under  the  vague  but  indispensable 
term  "  predisposition." 

Dosage  and  Virulence  of  Infecting  Bacteria. — In  the  case 
of  some  pathogenic  bacteria  a  single  bacterial  cell  may  be  capable  of 
infecting  a  highly  susceptible  animal,  whereas  with  a  less  susceptible 
animal  a  large  number  of  the  same  kind  of  bacteria  may  be  required. 
In  his  interesting  studies  on  the  relation  of  the  dosage  of  bacteria  to 
infection  Watson  Cheyne^  showed  that  whereas  a  single  virulent  bacillus 
of  rabbit  septicaemia  was  capable  of  causing  fatal  septicaemia  in  the 
highly  susceptible  rabbit,  in  tlie  less  susceptible  guinea-i)ig  the  fatal  dose 
was  300,000  bacilli  and  upward  ;  between  10,000  and  300,000  bacilli 
produced  abscesses,  and  smaller  doses  were  without  effect.  In  a  mouse 
a  single  bacillus  of  mouse  septica?mia,  and  in  a  guinea-pig  a  single  viru- 
lent anthrax  bacillus,  were  capable  of  producing  fatal  infection,  whereas 
in  rabbits  and  sheep  a  considerable  quantity  of  the  anthrax  bacilli  was 
required  to  kill  the  animals. 

Animals  are  in  general  insusceptible  to  small  quantities  of  the  pyo- 
genic cocci,  whether  introduced  sul)cutaue(iusly  or  into  the  circulation.  It 
generally  takes  several  hundred  thousand  of  the  cocci  to  produce  local 
abscesses  by  intravenous  or  subcutaneous  injection.  Man  is  more  sus- 
ceptible to  these  cocci. 

'  Watson  Cheyne,  The  British  Medical  Journal,  July  31,  1886. 


CONDITIONS  FAVORING   THE  DEVELOPMENT  OF  INFECTIONS.    289 

Thi.s  question  of  dosage  is  largely  one  of  individual  or  racial  suscept- 
ibility on  the  one  hand,  and  of  virulence  of  the  micro-organisms  on  the 
other  hand. 

The  kind  of  infection  produced  by  some  bacteria  varies  with  the 
dose.  It  often  liappens  that  the  inoculation  of  a  very  small  number  of 
certain  pathogenic  bacteria  produces  no  effect,  a  lai'ger  number  cause  only 
a  local  abscess,  and  a  still  larger  number  cause  fatal  septicemia.  Tiiis  is 
illustrated  by  the  micrococcus  lanceolatus,  some  varieties  of  the  strepto- 
coccus pyogenes,  and  other  pyogenic  cocci. 

We  are  familiar  with  varying  degrees  of  virulence  in  the  case  of  a 
large  number  of  patliogenie  bacteria.  Influences  known  to  be  capable 
of  affecting  the  vitality  and  the  virulence  of  bacteria,  such  as  sunlight, 
desiccation,  saprophytic  growth,  association  witii  other  bacteria  or  their 
products,  are  widely  operative  in  nature.  The  virulence  of  a  micro- 
organism depends  probably  maiidy  upon  its  capacity  to  form  toxic 
prnducts,  as  it  is  by  these  products  that  bacteria  chiefly  produce  their 
pathogenic  effects. 

Bacteria  which  enter  the  body  associated  with  their  toxic  products 
are  mucii  better  adapted  to  cause  infection  tiian  when  they  enter  deprived 
of  these  products.  Tiiese  toxic  substances,  by  damaging  immediately  the 
cells  and  fluids  which  protect  tlie  body  from  infection,  enable  the  invader 
to  gain  a  foothold  whicli  it  might  otiierwise  not  have  secured.  Vaillard 
claims  that  tetanus  spores,  deprived  by  heat  or  by  washing  of  their 
toxines,  are  incapable  of  germinating  in  the  animal  body  without  the 
aid  of  accessory  causes,  such  as  the  presence  of  other  micro-organisms, 
dirt,  other  foreign  substances,  necrotic  tissue,  although  the  spores  them- 
selves are  still  alive  and  in  suitable  media  capable  of  development.  If, 
however,  as  is  usual  in  our  laboratory  experiments,  the  spores  or  bacilli 
be  inoculated  with  the  toxin,  which  in  most  minute  doses  is  of  appalling 
potency,  tetanus  is  sure  to  develop.  In  fact,  our  experimental  tetanus 
is,  as  a  rule,  essentially  a  pure  intoxication. 

The  varying  results  which  follow  the  introduction  into  the  body  of 
pyogenic  cocci  derived  from  different  sources  depend  doubtless  in  part 
upon  whetlier  these  cocci  enter  tiie  tissues  already  equipped  with  a 
reserve  force  of  poisonous  products  or  must  Ix'gin  the  fight  unarmed. 
The  inoculation  of  infectious  material  coming  directly  from  the  human 
body,  as  from  a  case  of  puerperal  peritonitis,  and  received  perhaps  only 
in  a  puncture  or  scratch  of  the  skin,  may  manifest  disastrous  effects  with 
wliich  we  are  not  familiar  iu  inoculations  witii  our  artificial  cultures  of 
the  pyogenic  cocci  obtained  from  the  same  source. 

Tiie  micrococcus  lanceolatus,  the  streptococcus  pyogenes,  and  the 
pyogenic  stajihylococei  are  notable  for  tlie  wide  variations  of  their 
virulence.  The  lanceolate  cocci's  (piiekly  loses  its  virulence  in  artificial 
cultures. 

Tlie  writer  has  reported  observations  as  to  tiie  varying  virulence  of 
the  staphylococcus  aureus  cultivated  from  different  sources.  Some  broth 
cultures  were  fatal  to  rabbits  within  twenty-four  to  forty-eight  hours 
when  injected  into  the  circulation  in  tlic  dose  of  0.1  c.c,  and  other 
cultures  injected  in  the  same  way  produced  no  apparent  effect  in  the 
dose  of  1 .5  c.c.  Between  these  extremes  were  cultures  of  all  degrees  of 
intermediate  virulence.     In  the  majority  of  cases  0.2  to  0.3  c.c.  of  fresh 

Vol..  I.— 19 


290       GENERAL  BACTERIOLOGY  OF  SURGICAL  INFECTIONS. 

bouillon  cultures  killed  the  animal  witliin  three  to  seven  days  after 
intravenous  injection.  The  variations  in  virulence  of  the  stre])ti)r()(^('US 
pyogenes  are  even  more  strilvint;-.  Pathogenic  bacteria,  especially  pyo- 
genic cocci,  obtained  from  an  inf'ccte(l  individual  arc  more  likely  to  be 
highly  virulent  than  wlien  cultivated  from  other  sources.  There  are, 
however,  many  exceptions  to  this  general  rule. 

In  various  ways  the  weakened  virulence  of  pathogenic  bacteria  may 
become  augmented.  Among  th(!  most  important  of  those  ways  with 
which  we  are  acquainted  are  re])cated  ])assagc  through  the  animal  body, 
association  with  other  bacteria  or  their  products,  and  the  atldition  of  cer- 
tain chemical  substances. 

The  character  of  the  infection  varies  often  with  the  degree  of  viru- 
lence of  the  sjjecific  micro-organism.  Bacterial  species,  which  when  highly 
virulent  may  kill  cpiickly  \\itli  septica-mia,  may,  with  weakened  viru- 
lence, require  a  much  longer  jxM'iod  to  produce  the  same  eifects,  or  may 
give  rise  to  only  local  inHammatidu  without  general  infection.  It  is 
especially  with  bacteria  of  attenuated  virulence  that  the  matter  of 
dosage  may  be  a  controlling  factor. 

The  varving  virulence  of  the  ])yogenic  cocci  is  one  of  the  factors  in 
the  explanation  of  the  remarkably  diverse  effects  which  these  organisms 
are  capable  of  producing  in  the  animal  body.  These  cocci  may  under 
different  circumstances  cause  all  grades  and  kinds  of  inflammation,  serous, 
fibrinous,  suppurative ;  they  may  cause  localized  inflammations  and  gen- 
eral infections.  But  there  are  other  circumstances  besides  the  degree  of 
virulence  which  control  these  varying  results.  Equally  important,  in 
manv  cases  more  important,  controlling  factors  are  the  manner  of  inva- 
sion of  the  micro-organism  and  varitius  local  and  general  predisi)osing 
conditions. 

In  fact,  there  is  no  definite  and  constant  relation  between  the  charac- 
ter and  the  severity  of  an  infection  produced  in  man  by  pyogenic  cocci 
and  the  virulence  of  the  cocci  cultivated  from  the  case.  From  the 
gravest  septicicmias  cocci  of  slight  degrees  of  virulence  may  be  culti- 
vated, and  from  a  simple  epidermal  pustule  cocci  of  high  virulence,  as 
tested  upon  animals.  There  is  reason  to  believe  that  the  virulence  of 
tlie  micro-organisms  may  be  modified  during  the  course  of  an  infection, 
so  that  we  cannot  necessarily  draw  conclusions  as  to  the  primary  viru- 
lence of  the  organism  at  the  time  of  its  invasion  from  the  virulence 
noted  in  cultures  from  later  stages  of  the  disease. 

Bacteriai.  Association. — Bacteria  are  not  usually  found  in  the 
external  world  under  natural  conditions  in  pure  culture,  but  they  are 
mixed  together.  Mixed  infections  are  common  in  human  beings.  In 
suppurating  wovmds  we  usually  find  more  than  one  bacterial  species.  It 
is  of  importance  to  learn  the  relations  of  these  bacterial  associations  to 
infection.  We  are  at  present  only  imperfectly  informed  as  to  these  rela- 
tions, but  we  know  that  they  are  often  of  great  significance.  Only  the 
more  salient  points  which  directly  bear  upon  our  theme  can  be  con- 
sidered here. 

The  association  of  one  bacterial  species  with  another  may  be  without 
influence  upon  the  development  or  the  properties  of  either,  or  one  species 
may  be  favorable  to  the  gi'owth  or  enhance  the  virulence  of  another,  or 
one  species  may  be  antagonistic  to  another  or  in  various  ways  modify  its 


CONDITIOyS  FAVOJRjyG   THE  DEVELOPMEXT  OF  INFECTIONS.    291 

characters.  Bacteria  exert  their  influence  on  each  other  in  large  part 
throiioh  their  chemical  products,  and  it  is  often  possible  to  bring  about 
modifications  of  character  l)y  exposing  one  species  to  the  action  of  the 
chemical   products  of  another  species. 

The  pathogenic,  the  chromogenic,  the  fermentative,  and  the  other 
vital  manifestations  of  bacteria  may  be  influenced  by  their  combination 
with  each  other.  The  bacillus  pyocyancus  may  lose  its  power  of  pro- 
ducing ])igment  when  combined  with  certain  other  bacteria  (Miihsam 
and  Schinnuellmsch).  In  mixed  cultures  of  certain  bacteria  chemical 
products  mav  be  formed  and  fi^rmcntations  produced  which  neither  of 
the  species  in  the  culture  is  capable  of  producing  by  itself  alone  (Xencki, 
Burri,  and  Stutzer).  In  mixed  cultures  of  two  pathogenic  bacteria  a 
larger  amount  of  the  toxic  products  of  one  or  both  may  be  formed  than 
either  produces  when  in  pure  culture  (von  Schreider). 

The  effects  following  tiie  concurrent  inoculation  of  two  kinds  of 
bacteria  varv.  The  association  may  be  without  influence  as  regards 
infection.  The  result  may  be  that  the  develo])nicnt  of  a  deadly  species 
of  bacterium  is  checked  by  the  introduction  of  another  species  which  is 
relatively  harmless.  The  only  striking  instance  of  this  is  the  effect  of 
the  inoculation  of  the  streptococcus  of  erysipelas,  the  bacillus  of  Fried- 
liinder,  and  of  several  other  species  of  bacteria  simultaneously  with  or 
shortly  before  or  after  inoculation  with  the  anthrax  bacillus.  These 
bacteria  or  their  products  introduced  into  the  body  are  capable  of  pre- 
venting the  developing  of  the  anthra.x  bacillus  and  of  rescuing  the 
animal  from  certain  death  (Emmerich  and  others).  Various  explana- 
tions of  this  effect  are  given  by  different  writers.  The  effect  is  prob- 
ably referable  not  so  much  to  a  direct  antagonism  of  one  species  to  the 
otiier  as  to  an  augmentation  of  the  antibacterial  jiroperties  of  the  cells, 
which,  according  to  von  Dungern  and  Metschnikoff,  is  manifested  by 
increased  phagocytic  activity  of  the  leucocytes.  Bacteria  in  general 
wliich  cause  suppuration  may  thereby  prevent  the  development  of  the 
anthrax  bacillus  in  the  focus  of  suppuration. 

More  frequently  the  concurrent  inoculation  of  two  species  of  bacteria 
increases  the  danger  to  the  animal  from  one  or  both.  A  combination 
of  two  species,  each  in  itself  liarmless,  may  prove  fatal  to  the  animal 
(Roger).  A  bacterium  of  attenuated  virulence  may  become  augmented 
in  virulence  by  inoculation  in  combination  with  another  species  which 
need  not  necessarily  be  itself  jiathogenic,  nv  sometimes  simplv  in  com- 
l)ination  with  the  chemical  products  of  another  species.  The  following 
are  examples  of  the  exaltation  of  the  virulence  or  of  the  pathogenic 
effects  of  one  kind  of  bacteriinn  by  combined  inoculation  with  another 
kind  or  its  |>roducts  :  that  of  the  niici'ococcus  lanceolatus  by  combination 
with  the  proteus  vulga'ris,  the  anthrax  bacillus,  or  the  diphtheria  bacillus 
(Monti,  Pane,  Miihlmann,  Mya) ;  the  streptococcus  pyogenes  with  the 
proteus  vulgaris,  bacillus  prodigiosus,  bacillus  coli  communis  (Klein, 
Monod,  and  Macaigne) ;  the  pyogenic  sta|)]iyloc()cci  with  the  bacillus  pro- 
digiosus or  its  products  and  otiier  bacterial  ))r(iducts  (Grawitz  and  De 
Bary  and  others) ;  the  diphtheria  bacillus  with  the  streptococcus  ])vogenes 
or  its  products  (Roux  and  Yersin  and  others) ;  the  typhoid  bacillus  with 
the  streptococcus  pyogenes,  colon  bacillus,  and  proteus,  or  their  products 
(Vincent,  Sanarelli) ;  the  bacillus  coli  communis  M'ith  the  typhoid  bacil- 


292       GENERAL  BACTERIOLOGY  OF  SURGICAL  INFECTIONS. 

lus  and  the  streptococcus  pyogenes  (Pisenti  and  Hianclii-Mariotti) ;  the 
bacillus  of  symptomatic;  authrax  with  the  liacillus  jjrotligiosus  (Roller). 
Mention  has  already  been  made  oi'  the  pathological  importance  of  tiic 
association  of  the  tetanus  bacillus  with  other  bacteria.  Of  especial 
interest  are  the  experiments  of  Prudtieu  demonstrating  that  the  intra- 
tracheal injection  of  cultures  of  the  streptococcus  pyogenes  in  tuber- 
culous rabbits  leads  to  the  formation  of  regular  phthisical  cavities  in  the 
lungs — a  result  which  is  not  obtained  by  the  inoculation  of  either  micro- 
organism alone.  Jiernheini  has  demonstrated  that  the  dijilitln'ria  bacillus 
grows  more  luxuriantly  and  with  a  larger  production  (jf  toxin  in  the 
filtrate  of  streptococcus  bouillon  cultures  than  in  ordinary  bouillon. 

A  most  important  group  of  infections,  many  of  them  of  surgical 
importance,  is  furnished  by  the  secondary  invasion  of  pathogenic  bacteria 
in  the  course  of  various  infectious  diseases,  such  as  ty])hoid  fever,  tuber- 
culosis, diphtheria,  scarlet  fever,  small-pox,  and  other  exantliematous 
fevers.  The  streptococcus  pyogenes  is  more  frequently  the  infections 
agent  in  these  secondary  infections  than  any  other  organism,  but  the 
other  pyogenic  cocci  are  not  uncommonly  concerned.  The  primary 
infection  increases  susceptibility  to  these  common  pyogenic  cocci,  which 
often  find  the  way  open  for  their  invasion  by  some  lesion  of  an  exposed 
surface  of  the  body.  It  is  also  very  jirolialtle  that  the  primary  infection 
may  brine  about  conditions  which  enhance  the  virulence  of  the  bacteria 
concerned  in  the  secondary  infection.  Although  it  is  not  necessary  to 
suppose  that  these  common  secondary  invaders  are  always  derived  from 
tlu)se  \\hich  are  present  in  health  uj)on  exposed  mucous  membranes, 
nevertheless  they  doubtless  often  have  this  origin.  Pyogenic  cocci 
obtained  from  these  .■secondary  infections  ai-e  usually,  although  by  no 
means  always,  more  virulent  than  when  cultivated  irom  the  healthy 
mucous  membranes. 

Of  especial  frequency  and  importance  among  the  mixed  and  second- 
ary infections  here  in  consideration  is  the  association  of  the  tubercle 
bacillus  with  the  streptococcus  jn'ogenes,  the  tyj)hoid  bacillus  Avitli 
pyogenic  cocci,  and  the  diphtheria   bacillus  with  streptococci. 

The  characters  of  the  various  mixed  infections  are  probably  deter- 
mined less  by  a  direct  influence  of  one  bacterial  species  or  its  products 
upon  another,  although  this  factor  ajipears  in  some  cases  to  be  an  import- 
ant one,  than  by  the  action  exerted  by  one  or  both  species  upon  the 
resisting  powers  of  the  fluids  and  cells  of  the  body. 

Immunity  and  Pkedisposition. — In  no  class  of  infectious  diseases 
is  the  influence  of  ])redis])osition  as  an  etiological  factor  more  a])parcnt 
than  in  many  of  the  surgical  infections.  If  a  wound  could  be  kept 
entirely  free  from  pathogenic  bacteria,  it  would  not  suppurate,  no  matter 
how  favorable  in  other  respects  the  local  and  general  conditions  for  infec- 
tion might  be.  The  occurrence  of  suppuration  in  human  beings  from 
sterile  chemical  irritants  is  so  exceptional  that  we  need  not  consider  this 
form  of  suppuration  here.  It  is  not,  however,  possible  in  all,  or  even 
in  most,  cases  to  keep  bacteria  wholly  out  of  a  wound.  The  examina- 
tion of  so-called  aseptic  wounds  shows  with  great  frequency  the  presence 
of  bacteria,  and  notably  of  the  white  skin-coccus,  but  also  sometimes 
of  other  pyogenic  cocci,  including  the  staphylococcus  aureus.  Although 
the  cocci  found  under  these  circumstances  are  usually  of  -weakened  viru- 


CONDITIOXS  FAVORING   THE  DEVELOPMENT  OF  INFECTIONS.    293 

lence,  nevertheless,  as  shown  bv  Biidinger  and  others,  they  are  of  some 
virulence,  and  may  be  decidedly  virulent.  The  frequency  with  which 
pyogenic  bacteria  enter  wounds  is  by  no  means  expressed  by  the  fre- 
quency with  which  wounds  suppurate.  Every  surgeon  knows  that  in 
certain  persons  and  in  certain  conditions  of  the  body  a  wound  is  much 
more  likely  to  suppurate  than  in  others,  altliough  the  same  precautions 
are  taken  to  guard  against  the  entrance  of  micro-organisms.  It  is  there- 
fore a  matter  of  prime  importance,  no  less  of  practical  than  of  scientific 
interest,  to  learn,  so  far  as  we  may,  what  are  the  conditions  which  jire- 
dispose  an  individual  to  infection.  Unfortunately,  we  are  at  present 
only  imperfectly  informed  as  to  many  of  these  conditions. 

Predisposition  is  of  most  inqiortance  in  the  etiology  of  those  infec- 
tious diseases  which  are  caused  by  micro-organisms  to  which  the  individ- 
ual or  the  species  is  not  in  the  Iiigiiest  degree  susceptible.  Tiie  pyogenic 
cocci,  in  general,  belong  to  this  group  of  micro-organisms,  although  they 
may  exist  in  a  condition  of  such  exalted  virulence  that  predisposition 
becomes  a  factor  of  no  significance. 

The  degree  of  susceptibility  to  a  specific  micro-organism  influences 
not  only  the  capacity  to  acquire  the  infection,  but  also  the  course, 
severity,  and  character  of  the  infection.  In  an  individual  of  great 
susceptibility  a  micro-organism  of  attenuated  virulence  may  produce 
effects  which  in  a  relatively  insusceptible  person  can  be  accomplished 
only  by  a  highly  virulent  micro-organism  of  the  same  species. 

The  astonishing  variety  of  affections  which  may  under  different  cir- 
cumstances be  caused  by  pyogenic  cocci,  from  a  simple  epidermal  pustule 
to  tile  gravest  septicemia  and  pyarnia,  from  a  serous  to  a  suppurative 
inflammation,  are  to  be  explained  in  part  by  variations  in  the  local  or 
general  susceptibility  of  the  individual,  although,  as  already  explained, 
other  factors,  such  as  the  degree  of  virulence  of  the  organism,  the 
manner  of  invasion,  and  the  number  of  organisms  introduced,  are  also 
inq)ortant.  We  possess  aliundant  experimental  evidence  of  the  fact  that 
in  the  relatively  insusceptible  many  patliogenic  bacteria  remain  localized, 
causing  inflauiniation,  whereas  tiie  same  bacteria  in  the  highly  susceptible 
invatle  the  blood  and  internal  organs,  causing  general  septictemia. 

Ijimuxity. — Our  comprehension  of  the  nature  and  importance  of 
predisposition  as  a  factor  in  the  causation  of  infectious  diseases  has  been 
facilitatt'd  by  the  increase  of  our  knowledge  concerning  the  factors  upon 
M'iiicii  immunity  from  the  invasion  and  nuiltiplication  of  bacteria  depends; 
but  our  understanding  of  the  nature  of  innnuuity  is  still  most  incom- 
plete. It  is  not  necessary  for  our  purjjoscs  in  this  connection  to  enter 
into  a  detailed  consideration  of  the  various  doctrines  of  immunity, 
important  as  are  the  results  of  recent  investigations  upon  tliis  subject. 
It  will  suffice  to  state  briefly  tlie  more  inqiortant  facts  and  hypotheses 
so  far  as  they  bear  upon  the  (piestion  now  under  consideration.' 

We  distinguish  natural  or  hereditary  imuuuiity  from  acquired  immu- 
nity. Imnuinity  may  be  acquired  by  recovery  from  an  attack  of  a  specific 
infectious  disease,  or  may  be  artificially  produced  by  vaccination  with 
the  specific  micro-organism  or  its  products,  or  by  the  injection  of  the 

'  The  following  statements  concerning  immunity  are  taken  chiefly  from  the  fuller 
article  on  this  subject  by  the  writer  in  Pepper's  Teil-Iiook  of  the  Theory  and  Practice  of 
Medicine  by  American  Teachers,  vol.  ii.,  Philadelphia,  1894. 


294       GENERAL  BACTERIOLOGY  OF  SURGICAL  INFECTIONS. 

hliHKl-.scrum  or  otlier  fluids  fmin  individuals  rcndorcd  artificially 
iniiiiune. 

It  is  certain  that  the  various  kiniis  of  immunity  do  not  all  depend 
upon  the  same  causes.  The  leading  theories  of  immunity  may  be 
brought  into  two  classes — one  which  attributes  immunity  to  the  direct 
and  active  intervention  of  the  living  cells  of  the  body,  and  the  other 
which  explains  immunity  by  the  ])roperties  of  the  extra-cellular  fluids. 
In  the  last  analysis  these  properties  of  the  body  fluids  nnist  dei)eud 
upon  the  activities  of  cells,  so  that  we  must  have  recourse  either  directly 
or  indirectly  to  cellular  functions  in  any  adequate  explanation  of  im- 
munity. 

The  leading  representative  of  the  cellular  theories  is  the  phagocytic 
theory,  so  elaborately  and  charmingly  developed  by  ^Nletschnikoff.  This 
supposes  that  immunity  depends  u})on  the  seizure  of  invading  micro- 
organisms by  anitt'boitl  cells,  chiefly  leucocytes  and  other  mesodermic 
cells,  and  the  subsequent  destruction  of  these  organisms  in  the  interior 
of  the  cells.  According  to  this  view  the  leucocytes  are  charged  with 
the  defence  of  the  l)ody  and  engage  in  a  veritable  conflict  \\ith  the 
parasites.  The  significance  of  inflammation,  according  to  Metsclmikotf, 
is  to  bring  the  leucocytes  to  the  seat  of  danger,  to  which  they  arc  attracted 
by  the  j^ositivcly  chemotactic  substances  furnished  by  the  micro-organ- 
isms. Immunity  is  acquired  when  the  phagocytes  have  gained  tolerance 
of  the  poisons  of  the  specific  micro-organism  and  are  no  longer  repelled 
by  them. 

There  exists  in  a  very  large  number  of  cases  unquestionably  a  paral- 
lelism between  phagocytosis  and  immunity,  but  the  action  of  phagocytosis 
is  by  no  means  always  apparent.  \ye  know  that  micro-organisms  may 
be  destroyed  by  extra-cellular  agencies  as  well  as  within  the  cells,  and  it 
is  a  fair  question  whether  the  micro-organisms  before  their  reception  by 
cells  have  not  already  been  damaged  by  these  other  agencies.  It  is  true 
that  jNIetschnikofF  has  proven  that  phagocytes  may  take  ujj  li\-ing  and 
virulent  bacteria,  and  that  these  bacteria  may  degenerate  and  die  in  the 
interior  of  cells,  but  he  has  not  shown  that,  as  a  rule,  bacteria  when  taken 
up  by  cells  have  suft'ered  no  injury  from  extra-cellular  agencies.  We 
possess  direct  observations  which  prove  that  bacteria  introduced  into  the 
body  may  degenerate  and  die  not  only  within  cells,  but  also  outside  of 
them  in  the  humors. 

The  humoral  theories  of  naturid  inuuunity  have  been  based  largely 
upon  the  demonstration  by  Nuttall,  Buchner,  and  others  of  the  bacteri- 
cidal properties  of  the  blood  and  other  fluids  of  the  body.  Buchner  has 
given  the  name  of  "  alexins,"  and  Hankin  that  of  "  defensive  protcids," 
to  these  bactericidal  substances.  The  bactericidal  alexins  are  believed 
by  Kossell  and  Vaughan  to  be  nucleins  or  nucleinic  acid.  Their  action 
is  not  exerted  equally  ujjon  all  bacteria,  and  there  is  often  no  parallelism 
between  the  ])resence  of  this  bactericidal  property  in  the  blood  of  the 
normal  animal  and  the  insusceptibility  of  the  animal  to  a  given  micro- 
organism. The  important  observation  has  been  made,  however,  that 
as  the  result  of  the  introduction  of  certain  micro-organisms  the  body 
fluids  may  acquire  bactericidal  proj)crties  as  regards  the  organism  intro- 
duced. 

The  search  for  the  origin  of  the  alexins  has  led  to  the  view  that  they 


b 


CONDITIONS  FAVORING   THE  DEVELOPMENT  OF  INFECTIONS.    295 

are  derived  directly  from  the  cells,  and  particularly  from  the  leucocytes. 
This  lias  led  to  a  partial  reconciliation  between  the  phagocytic  and  the 
most  prominent  humoral  tiieories  of  immunity.  The  leucocytes  and 
other  cells  are,  indeed,  tlie  defenders  of  the  body  against  intruding  micro- 
organisms. I'hey  furnisli  the  alexins,  the  weajions  of  attack.  AVhere 
they  accunudate  the  defensive  material  is  concentrated,  but  it  is  not 
necessary  that  the  bacteria  should  be  actually  incorporated  in  the  body 
of  the  cells,  although  the  germicidal  properties  may  be  more  intense 
within  than  without  tlie  cells.  Such  is  the  explanation  of  natural  inunu- 
nitv  now  adopted  l)y  Buchner  and  many  others. 

There  is  a  kind  of  acquired  inununity  wliich  is  not  known  to  have  a 
parallel  in  forms  of  natural  imnuuiity.  Tiiis  is  tlie  so-called  antitoxic 
immunity.  Here,  as  the  result  of  vaccination  with  the  specific  micro- 
organism or  its  products,  tiie  blood  and  fluids  of  the  immunized  animal 
have  acquired  the  property  of  neutralizing  the  poison  formed  by  the 
specific  organism  from  which  the  individual  has  been  immunized.  The 
principles  of  antitoxic  immunity  liave  been  worked  out  for  the  toxic 
infections,  tetanus  and  diphtheria.  The  same  principle  doubtless  holds 
good  for  acquired  immunity  from  some  other  diseases,  but  for  how  large 
a  number  we  cannot  say.  A  most  important  characteristic  of  this  anti- 
toxic immunity  is  that  by  successive  injections  of  increasing  amounts  of 
the  ])oisonous  substances  into  the  animal  the  antitoxic  or  immunizing 
power  of  the  fluids  can  be  augmented  to  an  astounding  degree.  It  is  in 
this  way  that  the  antitoxic  power  of  the  fluids  may  be  rendered  sufticiently 
high  to  exert  curative  effects  when  injected  after  the  reception  of  the 
specific  micro-organism  or  its  ju'oducts.  This  so-called  serum-therapy 
has  thus  far  Ijcen  apjilied  with  beneficial  results  only  to  cases  of  tetanus 
and  of  di[)litlicria,  and,  as  regards  human  beings,  it  is  more  efficient  in 
diphtiieria  tiian   in  tetanus. 

Local  Piiedisposition. — The  term  "  predisposition  "  is  often  used 
in  a  loose  sense  to  designate  all  sorts  of  conditions  M'hich  increase  the 
chances  of  infection,  or  which  augment  susceptibility  to  infection,  or 
which  influence  the  localization,  duration,  character,  or  severity  of  infec- 
tions. A  name  which  is  used  to  refer  to  conditions  belonging  to  such 
ditterent  categories,  having  often  nothing  in  common,  is  of  course  objec- 
tional)le,  but  common  usage  sanctions  the  term,  and  there  appears  to  be 
no  lietter  one  under  which  to  include  the  various  points  here  to  be  con- 
sidered. 

We  distinguish  racial  and  individual  predisposition,  inherited  and 
acquired  predisposition,  local  and  general  ])redisposition. 

Instances  abound  of  diflerences  in  susceptibility  to  infectious  diseases 
between  ditt'erent  species  of  animals,  and  tiiere  are  differences  also  between 
different  races  of  nien  ;  but  tho  most  important  kind  of  predisposition, 
as  regards  those  surgical  infections  which  we  are  here  considering,  is 
individual  predisposition. 

This  iudividnal  |)redisposition  may  be  either  inherited  or  acquired. 
It  may  pertain  only  to  one  part  or  to  certain  parts  of  the  body,  or  it  may 
belong  to  the  body  as  a  whole.  A\'e  cannot  in  many  instances  determine 
whether  the  predisposition  is  local  or  general,  and,  indeed,  it  is  often 
imjiossible  to  draw  any  sharp  dividing-line  between  local  and  general 
predisposition. 


296       GENERAL  BACTERIOLOGY  OF  SURGICAL  INFECTIONS. 

Local  predisposition  may  be  limited  to  one  or  more  of  the  portals  of 
entry  for  miero-(jriianisnis,  or  it  may  exist  at  some  point  within  the  Ixidy, 
constitiitint;-  a  so-called  locus  minoris  resistcntiie. 

We  shall  consider  first  prcdisposinii'  causes  of  infection  at  the  portals 
of  entry.  We  shall  have  in  view  under  this  headinj;-  min'c  pai'ticidarly 
causes  which  act  locally,  hut  it  is  to  be  understood  that  general  ])redis- 
posing  factors  to  be  described  later  may  produce  local  predisposition. 

Under  the  heading  of  " Intlannnation  produced  by  Bacteria"  Dr. 
Councilman  in  the  pre(;eding  article  has  described  the  intluenec  upon 
pyogenic  infections  of  many  local  predisposing  factors,  such  as  the 
character  of  the  tissue  invaded,  local  ana-mia,  passive  hypera^mia,  the 
withdrawal  of  nerve-impulses  from  a  part,  rapidity  of  absorption,  the 
introduction  of  chemical  bacterial  jiroducts,  the  presence  of  foreign 
bodies,  jirevious  attacks  of  inflammation  ;  and  the  reader  is  referred  to 
Dr.  Councilman's  article  for  these  points.  It  has  there  been  made  clear 
that  any  interference  with  the  integrity  of  the  tissues  and  of  the  local 
blood-  and  lymph-circulation  is  likely  to  render  them  more  susce]>tible  to 
jiyogcnic  agents,  and  to  influence  nnfiivorably  the  character  and  course 
of  a  subsequent  inflammation.  Wounds  through  a  thick  layer  of  adipose 
tissue  or  cicatricial  tissue  or  other  poorly-vasenlarized  parts  are  less  able 
to  resist  the  action  of  jwogenic  bacteria  than  wounds  of  such  vascular 
parts  as  the  face. 

To  the  predisposing  conditions  enumerated  may  be  added  redema  of 
tlie  tissues.  How  important  this  is  may  be  inferred  from  the  frequency 
with  which  erysipelas  and  suppuration  follow  so  slight  an  injury  as 
puncture  of  an  a?dematons  scrotum  or  leg.  Biidinger  found  that  ])vo- 
genic  cocci  so  weakened  in  \-irulence  as  to  produce  no  effect  Mhen  inoc- 
ulated into  the  normal  ear  of  a  rabbit  set  up  local  suppuration  Mhen 
inoculated  into  an  ear  rendered  hy2)er8emic  and  a?dematous  by  tempo- 
rary application  of  a  rubber  band  around  the  root  of  the  ear. 

The  withdrawal  of  nerve-impulses  from  a  part  may  increase  its  lia- 
bility to  infection.  The  factors  here  concerned  are  various,  the  most 
apparent  ones  being  anaesthesia,  disturbances  in  the  lymphatic  and 
blood  circulation,  and  nutritive  changes.  The  question  as  to  the  exist- 
ence of  special  trojihic  nerves,  the  interference  with  whose  function  pre- 
disposes the  part  to  infectious  inflammations,  has  been  considered  by 
Dr.  Councilman.  In  a  personal  conmiunication  Dr.  Weir  Mitchell  has 
kindly  favored  the  writer  with  the  following  expression  of  his  views 
on  this  point :  "  I  think  it  true  that  the  withdrawal  of  nerve-im])nlses 
from  a  part  favors  infection  ;  that  the  withdrawal  of  nerve-influence 
with  partial  failure  of  circulation  in  some  cases  of  injury  still  further 
favors  infection  ;  that  there  is  a  condition  of  traumatic  nerve-irritation 
which,  probably  by  its  abnormal  influence  on  nutrition,  favors  infection. 
A  partial  injury  of  a  nerve  sets  up  local  neuritis  and  may  bring  on  idcers 
of  a  jiecnliar  character.'  It  seems  to  me  that  if  we  injure  a  nerve-supply, 
the  changes  in  muscular  and  nerve  conditions  which  immediately  take 
place  would  favor  such  chemical  changes  in  the  tissues  as  to  make  them 
more  or  less  susceptible  to  infection." 

Abnormalities  in  the  secretions  on  exposed  mucous  surfaces  and  in 

'  Interesting  examples  of  sucli  uleere  nre  here  cited  by  Dr.  Mitcliell  from  the  forth- 
coming book  of  his  son,  Dr.  Jolin  H.  Jlitcliell,  on  Nen-e-injuries  and  their  Remote  Results. 


CONDITIONS  FAVORING   THE  DEVELOPMENT  OF  INFECTIONS.    297 

the  glands  communicating  with  them  may  be  a  local  predisposing  cause 
of  iuf't'ction.  Obstruction  to  the  outflow  of  secretions,  and  the  presence 
of  calculi  or  foreign  Ijodies  in  cavities  or  glandular  ducts  opening  upon 
exposed  surfaces  are  important  prcdisjiosing  causes  of  infection,  as  is 
exem[)lificd  by  inflammations  of  the  vermiform  appendix,  renal  pelvis, 
urinary  and  gall-ldadders,  urethra,  the  l)iliary,  pancreatic,  and  salivary 
ducts. 

In  general,  all  traumatic  and  pathological  lesions  of  exposed  surfaces 
of  the  I)ody,  such  as  wounds,  hemorrhages,  necroses,  waxy  degeneration, 
inflammation,  ulcers,  stricture,  strangulation,  pcrfn'ation,  increase  in 
greater  or  less  degree  the  opportunities  for  the  entrance,  lodgement, 
and  multiplication  of  pyogenic  and  other  micro-organisms. 

A  suppurating  surface,  however,  offers  considerable  resistance  to  the 
growth  and  invasion  into  the  body  of  most  jiathogenic  bacteria.  Pus  is 
endowetl  with  marked  bactericidal  properties,  both  in  its  corpuscular 
elements  and  its  fluid  constituents,  and  tlie  o]>portunities  for  absorjition 
from  a  suppurating  surface  are  nuich  less  favorable  than  from  a  fresh 
wound.  Scstini  found  that  the  bacilli  of  anthrax  and  of  rabljit  sejjtica- 
mia  when  applied  to  a  suppurating  wound  of  tlie  rabbit's  skin  produced 
no  infection,  although  they  readily  did  so  when  introduced  into  a  fresh 
wound.  The  existence  of  sujipui-ation,  however,  lowers  the  general 
resistance  of  the  body  to  bacteria. 

The  various  lesions  which  interrupt  the  continuity  and  integrity  of 
the  exposed  surfaces  of  the  body  become  most  dangerous  channels  of 
infection  when  the  general  resistance  of  the  body  to  infectious  agents  is 
lowered,  as  in  various  infectious  fevers  and  constitutional  diseases. 

J^xperiments  and  clinical  observations  have  been  made  with  reference 
to  tile  amount  of  damage  to  the  intestinal  coats  which  is  requisite  in 
order  to  permit  the  passage  of  bacteria  from  the  intestinal  canal  into 
the  peritoneal  cavity.  Most  observers  have  found  the  fluid  in  the  sac  of 
a  strangulated  intestinal  hernia  free  from  bacteria  in  the  great  majority 
of  cases.  Garre  found  bacteria  only  once  in  eight  cases ;  Rovsing  did 
not  find  them  at  all  in  five  eases  ;  nor  did  Ziegler  in  five  cases ;  Tavel 
and  Lanz  obtained  a  positive  result  only  twice  in  seventeen  cases  of  in- 
testinal strangulation  ;  in  two  out  of  three  omental  strangulations  they 
found  l)actcria  ;  Tietze  found  bacteria  in  four  out  of  nine  cases,  with  the 
possibility  that  in  some  of  the  four  cases  they  were  accidentally  intro- 
duced from  without.  Sanguineous  hernial  fluids  with  bloody  infiltration 
of  the  intestinal  coats  were  observed  without  the  presence  of  bacteria,  and 
even  the  fluid  in  sacs  containing  necrotic  intestine  did  not  always  contain 
bacteria.  The  presence  of  fibrinous  peritonitis  over  strangulated  intestine 
does  not  necessarily  involve  the  presence  of  Iwctcria  in  the  exudate,  as 
this  form  of  peritonitis  may  be  caused  by  the  absorption  of  the  chemical 
products  of  bacteria  from  the  intestine  (chemical  peritonitis).  Definite 
relations  lietween  the  condition  of  the  intestine  and  the  presence  of  bac- 
teria in  the  hernial  sac  were  not  ol)scrvc<i. 

For  some  at  present  inexplicable  reason  Boenneckcn  found  bacteria 
in  the  sacs  of  all  of  the  eight  strangidated   iiernias  which  he  examined. 

Arndt  has  shown  by  exj)eriments  on  rabbits  that  bacteria  may  pass 
through  the  strangulated  intestinal  wall  without  the  existence  of  necrosis 
of  the  intestine,  and  when  the  condition  of  the  intestine  is  such  that  it 


298       GENERAL  BACTERIOLOGY  OF  SURGICAL  INFECTIONS. 

quickly  returns  to  the  normal  state  upon  relief  from  the  stranjyulation. 
The  presence  of  bacteria  in  the  hernial  fluid  does  not  necessarily  involve 
the  development  of  peritonitis,  'i'lie  conditions  which  jicriuit  l)actcria  to 
wander  from  the  intestine  tin'oug'li  its  wall  into  the  peritoneal  cavity 
have  not  as  yet  been  made  clear.  Tietze  has  shown  that  the  fluid  from 
a  hernial  sac  possesses  marked  bactericidal  power  over  some  intestinal 
bacteria.' 

The  entrance  of  the  colon  bacillus  into  the  circulation  is  usually,  in 
our  cxjicrience,  associated  with  some  lesion  of  the  intestinal  nnicosa, 
although  this  is  not  invariably  the  case.  Absorption  of  pathoi,renic  bac- 
teria, jiarticularly  the  pyogenic  cocci,  from  the  diseased  intestinal  mucosa 
is  a  fruitful  source  of  various  infections  of  internal  parts,  and  many 
cases  regarded  as  cryptogenetic  septico-pysemia  have  this  origin. 

The  importance  of  accessory  and  jn-edisposing  causes  of  inflanmia- 
tions  due  to  bacteria  is  nowhere  better  illustrated  than  in  the  etiology  of 
peritonitis,  as  has  been  set  forth  l)y  Dr.  Councilman  on  page  180.  There 
are  two  principal  classes  of  predis])osing  causes  of  peritonitis — namelv, 
substances  which  damage  the  endothelial  cells  of  the  peritoneum,  and 
solid,  unabsorbable  substances. 

Of  especial  importance  to  the  surgeon  is  a  knowledge  of  tlie  local 
and  general  predisposing  causes  of  the  infection  of  womids.  The  gen- 
eral predisposing  fiictors  we  shall  consider  later.  From  what  has  alirady 
been  said,  it  is  ap])arent  that  while  the  surgeon  should  use  every  effort  to 
keep  bacteria  out  of  a  wound,  he  should  refrain  so  far  as  possible  from 
doing  anything  which  interferes  with  the  power  of  the  fluids  and  cells  to 
ovei'comc  invading  micro-organisms. 

Among  the  local  conditions"  which  have  been  found  fiivoralde  to  the 
growth  in  wcjunds  of  l)act('ria  which  otherwise  might  be  disjjosed  of  by 
the  tissues  and  animal  fluids  without  harm  may  be  mentioned  strangu- 
lation of  masses  of  tissue  l)y  ligatures ;  the  presence  of  foreign  bodies, 
such  as  drainage-tubes  and  coarse  ligatures ;  interference  with  the  cir- 
culation and  absorption  and  the  vitality  of  tissues  resulting  from  undue 
pressure  or  tension  ;  dead  spaces ;  accumulation  of  the  fluid  and  solid 
discharges  from  a  wound,  especially  when  associated  with  tension  ;  necro- 
sis and  degeneration  of  tissues  caused  by  the  contact  of  strong  chemical 
irritants.  If  it  were  within  the  power  of  the  surgeon  to  keep  bacteria 
entirely  out  of  wounds  or  to  destroy  them  without  damage  to  the  tissues 
after  they  enter,  the  conditions  just  mentioned  could  not  by  themselves 
alone  cause  infection,  but  this  power  he  does  not  at  present  possess.  The 
so-called  aseptic  A\-ound  of  the  surgeon  is  not  usually  aseptic  in  the 
bacteriological  sense  ;  that  is,  free  from  bacteria. 

The  following  objections  to  the  insertion  of  drainage-tubes  into 
Avounds  have  been  elsewhere  formulated  by  the  M'riter :  ^  First.  They 

'  For  the  literature  and  the  most  important  experiments  and  observations  thus  far 
made  upon  the  subject  of  bacteria  in  hernial  sacs  consult  Tavel  and  Lanz,  "  Ueber  die 
Aetiologie  der  Peritonitis,"  Mittlieilntu/eii  «i(s  Ktiniken  nnci  mad.  Instil,  d.  Schceiz,  Basle 
and  Leipzig,  189:3;  Arndt,  "Ueb.  d.  Diircb];issie;keit  d.  Darmwand  eingeklemmter  Briiche 
fiir  Mikroorganismen,"  ibid.,  1893;  and  Tietze,  Arrh.f.  klin.  Cliirurgii;  I'd.  49. 

^The  writer  wishes  to  acknowledge  his  indebtedness  to  his  colleague,  Dr.  William 
S.  Halsted  of  the  Johns  Hopkins  Hospital,  for  information  and  numerous  suggestions  as 
to  tlie  influence  of  many  local  and  general  causes  predisposing  to  the  infection  of  wounds. 

■'  Welch,  "  Some  Considerations  concerning  Antiseptic  Surgery,"  The  Maryland 
Medical  Journal,  Xov.  14,  1S91. 


COSDITIOXS  FA  VORIXG   THE  DEVELOPMENT  OF  INFECTIONS.    299 

tend  to  remove  bacteria  which  may  get  into  a  wound  from  the  direct 
bactericidal  influence  of  the  cells  and  animal  juices.  Second.  Bacteria 
may  travel  bv  continuous  growth  or  in  other  ways  down  the  sides  of  a 
drainage-tube,  and  so  penetrate  into  a  wound  which  they  otherwise  would 
not  enter.  We  have  repeatedly  been  able  to  demonstrate  this  mode  of 
entrance  into  a  W(jund  of  the  white  staphylococcus  found  so  commonly 
in  the  epidermis.  The  danger  of  leaving  any  part  of  a  drainage-tube 
exposed  to  the  air  is  too  evident  to  require  mention.  Third.  The  chang- 
ing of  dressings  necessitated  by  the  presence  of  drainage-tubes  increases 
in  pnipDrtion  to  its  frequency  the  chances  of  accidental  infection.  Fourth. 
The  drainage-tube  keeps  asunder  tissues  which  might  otherwise  inniic- 
diately  unite.  Fifth.  Its  presence  as  a  foreign  body  is  an  irritant  and 
increases  exudation.  'Si.iih.  The  withdrawal  of  tubes  left  any  consider- 
able time  in  wouuds  breaks  up  forming  granulations,  and  thus  both  pro- 
longs the  process  of  repair  and  opens  the  way  for  infection.  Cxrannlation 
tissue  is  an  olistaclc  to  the  invasion  of  pathogenic  bacteria  from  the  sur- 
face, as  has  l)een  proven  by  experiment.  Seventh.  After  remo\-al  of  the 
tube  there  is  left  a  tract  prone  to  suppurate  and  often  slow  in  healing. 

The  advantage  from  the  employment  of  drainage-tubes  or  other  drain- 
age material  is,  of  course,  the  removal  of  secretions,  and  this  indication 
becomes  an  urgent  one  if  the  cavity  with  which  the  tube  connnunicates 
is  infected  and  su])purates.  In  a  given  case  the  surgeon  nuist  weigh  the 
advantages  and  the  disadvantages  and  act  according  to  his  judgment. 
The  practice  of  most  surgeons  at  the  jjrcsent  time  (jf  restricting  within 
much  narrower  limits  than  formerly  the  use  of  drainage-tubes,  and  of 
discarding  them  for  all  wounds  which  offer  a  fair  prospect  of  primary 
union,  is  a  distinct  advance  in  the  technique  of  antiseptic  surgery. 

The  presence  of  blood  in  a  wound  is  not  itself  to  be  desired,  and 
modern  surgeons  justly  lay  stress  upon  prompt  and  careful  ha;mostasis 
in  surgical  operations.  Blood  in  a  wound  is  not,  however,  so  dangerous 
a  thing  as  some  have  supposed  it  to  be,  and  where  for  the  obliteration 
of  cavities  in  a  wound  the  choice  lies  between  a  blood-clot  and  the  intro- 
duction of  foreign  substances,  or  the  exercise  of  undue  tension  by  sutures, 
or  the  application  of  a  very  large  number  of  sutures,  or  forcible  ]3res- 
sure,  it  is,  as  a  rule,  better  to  take  the  chances  that  the  spaces  will  till 
with  blood  (Halsted).  Blood  possesses  bactericidal  properties,  and  experi- 
ments made  by  the  writer  and  Howard  '  showed  that  virulent  pyogenic 
staphylococci  injected  into  blood-clots  which  had  been  allowed  to  fill 
wound-cavities  did  not  multiply  and  occasioned  no  suppuration.  Joiui 
Hunter  was  find  of  dwelling  upon  what  he  called  the  vitality  of  blood, 
and  John  Chicne  has  directed  attention  anew  to  similar  views.  Schcde 
brought  prominently  to  the  notice  of  surgeons  the  value  of  the  blood-clot 
in  the  healing  of  a  certain  class  of  wounds,  and  Halsted '"  further  extended 
the  field  of  its  application.  The  unintended  presence  of  blood  in  a  wound 
by  occasioning  undue  tension  and  in  other  ways  may  be  a  dangerous 
thing,  and  is  something  very  ditferent  from  the  purposeful  apj)lication  of 

'  Welch,  "  Conditions  iimlerl.ving  thi'  Infection  of  Wonnds,"  Transactions  of  tlie 
Second  Congress  of  American  Phijuiciann  and  Siirf/eoiia,  vol.  ii.,  1891. 

^  Halsted,  "  The  Treatment  of  Wounds  with  especial  reference  to  the  Value  of  the 
Blood-elot  in  the  Management  of  Dead  Sjiaces,"  Tlic  Johns  Hopkins  Hospital  Peporls,  vol. 
ii.  No.  o. 


360       GENERAL  BACTERIOLOGY  OF  SURGICAL  INFECTIONS. 

the  metliod  of  healing  by  so-called  organization  of  blood-coagula.  It  is 
of  the  first  importance  to  prevent  so  far  as  possible  all  tension  in  a 
wonnd. 

T^ndne  stress  is  sometimes  laid  iijion  artificial  devices  to  close  the  so- 
called  dead  spaces  of  a  wound.  These  spaces  when  not  drained,  nor 
stutted  with  foreign  substances,  nor  obliterated  by  siitui'es  or  pressure, 
nor  pei'mitted  to  fill  with  blood,  do  not,  unless  very  large,  remain  empty 
spaces.  They  quickly  fill  with  exudations  of  fluids  and  cells,  and  these 
fluids  and  cells  possess  antibacterial  jiroperties  as  well  as  blood.  For 
cavities  with  unyielding  walls,  such  as  those  in  bone,  the  blood-(dot 
method  of  treatment  has  been   found  especially  useful. 

Surgeons  are  not  agreed  as  to  the  value  of  the  application  of  antiseptic 
fluids  and  substances  to  fresh  wounds.  There  has  been  in  recent  years, 
under  the  name  of  asejttic  surgery,  a  general  tendency  to  consider  them 
useless  or  harmful,  but  .some  surgeons  still  advocate  the  antiseptic  irri- 
gation of  fresh  wounds.  The  (jucstion  is  one  which  can  lie  decided  only 
by  clinical  ex^jcrience.  The  experimental  data  bearing  upon  the  (pies- 
tion  are  the  only  ones  appropriate  to  consider  here. 

The  principal  objections  urged  against  the  employment  of  the  a]ipli- 
cation  of  such  disinfectants  as  corrosive  sublimate  and  carbolic  acid  to 
fresh  wounds  are — -fir.'^t,  that  tliey  accomplish  little  or  nothing  in  the  way 
of  destroying  bacteria  wliich  may  have  entered  the  MOund  ;  and,  second, 
that  they  cau.se  necrosis  or  other  impairment  of  the  tissues,  and  thereby 
^\•eaken  or  abolish  the  antibacterial  properties  of  the  tissues,  and  thus 
predispose  to  infection. 

The  conditions  for  the  destruction  of  bacteria  by  chemical  disinfect- 
ants in  the  fluids  and  tissues  of  the  animal  body,  even  -when  the  bacteria 
are  only  upon  an  exposed  surfiice,  are  most  unfavoral)le  as  compared 
Avith  those  in  experiments  with  the  same  agents  in  test-tubes.  The 
experiments  of  Schimmelbuseh,  already  cited,  do  not,  as  he  seems  to 
suppose,  demonstrate  the  uselessness  of  antiseptic  applications  to  wounds 
in  general.  He  found  that  the  fatal  infection  of  mice  with  the  bacillus 
anthracis  and  that  of  rabbits  with  tJie  bacilli  of  rabl>it  septicsemia,  intro- 
duced in  large  number  into  fresh  wounds,  could  not  be  prevented  by  tlie 
irrigation  of  the  wound  with  corrosive  sublimate  (1  :  1000)  or  carbolic 
acid  (5  per  cent.)  or  other  antiseptics.  But  some  of  the  bacteria  thus 
introduced,  as  has  already  been  ex])lained,  are  immediately  or  very  soon 
al)sorlicd  from  fresh  wounds,  and  if  one  bacillus  or  a  very  few  bacilli  of 
the  kind  used  by  Schimmelbuseh  were  thus  absorbed,  the  death  of  the 
animal  was  sure  to  follow;  whereas  a  similar  absorption  of  a  few  ordinary 
pyogenic  cocci  is  usually  without  significance.  It  is  evident  that  these 
experiments  are  not  conclusive  as  to  the  influence  of  antiseptics  upon 
bacteria  which  remain  in  the  wound,  and  are  not  applicable  to  the  ordi- 
nary conditions  of  wound-infection  during  a  surgical  operation. 

Henle'  in  his  experiments  conformed  more  closely  to  conditions  of 
wound-infection  in  man.  He  found  that  in  wounds  of  the  rab1)it's  ear 
inoculated  with  streptococcus  ])us  the  streptococci  remained  in  tin' wound 
for  six  hours,  after  which  the  cocci  began  to  occupy  the  neighboring 
lymph-spaces.  He  found  that  regularly  up  to  the  end  of  the  second 
hour  a  complete  disinfection  of  the  M'ound  with  sublimate  (1  :  1000)  or 

'  Henle,  Cenlralblalt  /iir  Chirurgie,  1894,  No.  30,  Beilage. 


CONDITIONS  FA  VOBING  THE  DEVELOPMENT  OF  INFECTIONS.    301 

carbolic  acid  (4  per  cent.)  could  be  attained,  and  that  even  after  six  hours 
the  disinfection  sometimes  })revented  tiie  development  of  the  disease,  and, 
if  not  completely  successful,  rendered  the  subsc(|Ui'nt  infection  milder  than 
in  the  inoculated  control  ear  wliicli  was  not  disinfected. 

Loffler  has  shown  bv  his  carcftd  tests  of  the  action  of  various  anti- 
septic substances  upon  diphtheritic  throats  that  it  is  possible  to  destroy 
the  superficial  bacteria  by  antiseptics  without  serious  injury  to  the  tissues. 
It  is  possible  that  disinfectants,  without  actually  killing  bacteria,  may 
restrain  their  power  of  development  or  weaken  their  virulence. 

Messner'  experimented  by  inocidating  fresh  wounds  of  rabbits  with 
pus  or  with  cultures  eontaininji'  pyogenic  cocci,  wiiich  caused  [)rogressive 
phlegmonous  inflammation  with  fatal  termination.  He  found  that,  with 
one  exception,  all  of  the  ten  wounds  inoculated  with  the  cocci,  and  then 
irrigated  with  sterile  salt-solution  and  treated  aseptically,  suppurated, 
witli  the  development  of  progressive  phlegmons  which  killed  the  animal 
Mithin  two  weeks.  On  the  other  hand,  all  of  the  ten  wounds,  with  one 
exception,  similarly  inoculated  and  treated  antiseptically  with  lysol  or 
3  per  cent,  carbolic-acid  solution,  healed  and  the  animals  survived.  Two 
of  the  wounds  treated  antisejjtically  healed  without  suppuration ;  the 
remaining  eight  suppurated,  showing  that  the  cocci  had  not  actually 
been  destroyed,  but  the  process  remained  localized.  Pus  from  the 
wounds  treated  aseptically  presei'ved  its  virulence,  whereas  pus  from  the 
wounds  treated  antiseptically  was  devoid  of  virulence  when  inoculated 
into  animals. 

Hermann  and  others  have  shown  that  if  carbolic  acid,  corrosive  sub- 
limate, and  various  other  chemical  irritants  be  injected  subcutaneously 
into  the  tissues  and  soon  afterward  pyogenic  micro-organisms  be  injected 
into  the  same  locality,  the  formation  of  an  abscess  is  much  more  likely 
to  follow  than  when  the  bacteria  are  injected  into  the  healthy  tissues. 
But,  as  Messner  has  shown,  a  similar  favoring  influence  upon  the  devel- 
opment of  suppuration  under  these  circumstances  is  exerted  by  the  injec- 
tion of  common  salt-solution  into  the  subcutaneous  tissues.  These  exper- 
iments are  not  a])])licable  to  the  conditions  existing  in  an  open  wound, 
Imt  tliev  confirm  clinical  observations  as  to  the  great  danger  of  intro- 
ducing into  tlie  subcutaneous  tissues  of  man,  with  a  hypodermic  syringe, 
fluids  containing  pyogenic  l)acteria. 

Uncpiestionably,  the  presence  of  necroses,  such  as  may  be  produced 
by  strong  chemical  disinfectants,  -jiredisposes  to  pyogenic  infection.  In 
some  situations,  as  in  a  closed  cavity  like  the  jieritoneal,  the  jiresence  of 
even  superficial  necroses,  which  may  afl'ect  oidy  the  endothelial  cells,  is 
an  important  ])redisposing  cause  of  infection,  but  only  experience  can 
decide  whetiier  such  slight  sujierficial  necrosis  or  other  injury  wliich  the 
ordinary  antiseptics  may  prodnce  in  an  external  wound  is  in  itself  an 
important  predisposing  factor  in  the  pyogenic  infection  of  wounds,  or 
even  if  a  predisposing  factor  is  not  more  than  counterbalanced  by  bene- 
ficial influences  exerted  by  tlie  a|)plication  of  antiseptics.  Messner  has 
reported  experiments  on  rabl)its  which  seem  to  show  that  the  irrigation 
of  fresh  wounds  with  3  per  cent,  carbolic-acid  solution  does  not  lessen 
the  \ital  resistance  of  the  tissues  in  a  wound  to  subsequent  inoculation 
with  pyogenic  cocci. 

'  Jlessner,  Jhid. 


302        GENERAL  BACTEBIOLOaY  OF  SUROTCAL  INFECTIONS. 

Experiments  upon  animals,  tlicrcforc,  favor  ratlior  than  o])post'  the 
antiseptic  treatment  of  wounds,  as  distinguished  from  so-ealled  asepsis. 

We  turn  now  to  the  consideration  of  local  predisposition  existing  at 
some  jioint  within  the  body,  the  so-called  locus  minoris  resisteutise.  After 
the  infectious  agents  have  passed  through  the  portal  of  entry  and  entered 
the  general  circulation  tluy  may  find  local  conditions  favoring  their  lodge- 
ment and  development.  Without  such  local  predisposition  they  are  often 
incapable  of  doing  any  harm. 

Injury,  inflammation,  and  other  pre-existing  disease  of  an  internal 
part  are  important  and  common  conditions  favoring  the  lodgement  and 
growth  of  micro-organisms.  The  classical  experiment  of  Chauveau  many 
years  ago  demonstrated  the  ])redisposition  of  injured  internal  parts  to 
infection.  He  twisted  off  without  ru])ture  of  the  skin  one  of  the  testicles 
of  a  young  ram  from  its  vascular  connections  (bistournage),  and  observed 
that  when  he  had  injected  shortly  before  the  operation  putrid  fluid  con- 
taining micro-organisms  directly  into  the  circulation  the  injured  testicle 
became  the  seat  of  septic  gangrene,  while  without  such  injection  the  tes- 
ticle became  neci'otic  and  was  absorbed  without  becoming  infected. 

The  experiments  of  Rosenbaeh,  Orth  and  ^\  yssokowitch,  Prudden, 
and  others  have  shown  that  bacteria  do  not  readily  become  attached  to 
the  smooth  surface  of  the  heart-valves,  but  that  pyogenic  cocci  readily 
adhere  and  set  up  septic  endocarditis  when  the  valves  have  been  jjre- 
viously  torn  by  a  sterile  probe  passed  down  the  carotid  artery.  The 
predisposition  of  injured  joints  and  Ijones  to  the  settlement  of  pyogenic 
cocci  and  of  tubercle  bacilli  is  established  both  by  clinical  and  exper- 
imental observations.  Pyogenic  cocci  often  invade  foci  of  disease  caused 
primarily  by  other  organisms,  as  is  exemplified  in  tuberculous  and  gonor- 
rhoeal  arthritis,  actinomycosis,  echinococcus  cysts,  amoebic  abscesses  of 
the  liver,  etc.  In  some  situations,  particularly  in  the  kidney  and  urinary 
tract,  the  colon  bacillus  often  settles  in  pre-existing  foci  of  disease.  The 
ansemic  and  dry  conditicin  of  the  lung  induced  l)y  pulmonary  stenosis 
favors  the  development  of  pulmonary  tuberculosis.  The  hypersemic  and 
moist  condition  associated  with  mitral  regurgitation  is  comjiaratively 
unfavorable  to  such  development,  although  by  no  means  excluding  this 
disease.  Pyogenic  cocci  not  infrequently  settle  in  the  joint-lesions  of 
locomotor  ataxia  and  cause  suppuration. 

The  existence  of  a  diseased  or  injured  part  within  the  body  by  no 
means  involves,  of  necessity,  the  localization  therein  of  infectious  jjro- 
cesses  which  may  be  caused  by  pathogenic  micro-organisms  in  the  circu- 
lation. The  damaged  part  may  be  spared  and  an  apparently  healthy 
part  attacked.  The  endeavor  to  obtain  experimentally  in  animals  the 
localization  of  suppuration  in  a  fractured  bone  or  other  injured  or  dis- 
eased part  by  pyogenic  cocci  injected  into  the  circulation  often  fails,  and 
in  the  hands  of  Rinne  failed  so  regularly  that  he  opposes,  although 
without  sufficient  reason,  the  whole  doctrine  of  locus  minoris  resistentise. 
By  a  different  line  of  expei'imentation  Gottstein  came  to  the  same  con- 
clusion as  Rinne. 

We  are  undoubtedly  able  in  some  cases  to  explain  the  localization  of 
an  infection  by  such  apparent  local  predisposing  causes  as  those  which 
have  been  mentioned,  but  in  many,  indeed  in  the  majority  of,  instances 
of  localized  infections  of  internal  parts  M'e  are  unable  to  give  any  satis- 


CONDITIONS  FA  VOEINO  THE  DEVELOPMENT  OF  INFECTIONS.    303 

factory  explanation  of  the  localization.  We  know  that  many  patho- 
genic micro-organisms  have  a  decided  preference  for  certain  organs  and 
tissues.  Tlie  injection  of  the  staphylococcus  aureus  into  the  circulation 
of  rabbits  does  not  lead  to  the  formation  of  abscesses  in  all  parts  of  the 
body,  althougli  tlie  cocci  must  be  carried  by  the  blood-current  evcry- 
Avhere.  The  abscesses  are  found  most  freijuently  in  the  kidneys  and 
myocardium,  sometimes  in  the  muscles  elsewhei-e,  and  in  young  ral)bits 
often  in  the  bone-marrow  and  joints.  To  say  that  the  tissues  in  one 
part  of  the  body  offer  better  conditions  for  the  growth  of  the  micro- 
organisms than  in  other  parts  is  only  another  way  of  saying  that  the 
organisms  jynxhice  disease  in  one  part  and  not  in  another.  Such  phrases 
offer  no  real  explanation  unless  the  nature  of  these  Ijetter  conditions  can 
be  defined. 

Sometimes  we  can  explain  the  localization  by  the  manner  of  recep- 
tion of  the  virus,  the  vascular  relation  of  the  part  to  infected  areas,  the 
size  and  number  of  the  capillaries,  the  velocity  of  the  circulation,  and 
the  readiness  witli  whicli  foreign  particles  arc  filtered  out.  We  know 
that  fine  particles  are  deposited  from  the  lymphatic  current  in  the  lymph- 
glands,  and  from  the  blood-circulation  chiefly  in  the  spleen,  mari'ow  of 
the  bones,  liver,  and  lymph-glands.  More  often  we  are  unable  to  give 
any  adequate  exiilanation  of  the  localization  of  an  infectious  process  in 
internal  parts  of  the  body. 

General  Predisposition. — Under  this  heading  we  shall  consider 
predisposing  causes  wiiich  act  more  or  less  generally  upon  the  whole 
body.  The  effect  of  such  causes  may  be  to  increase  the  susceptibility 
of  the  whole  body  or  only  of  pai'ticular  pai'ts  of  the  body  to  infection. 
The  factors  here  concerned  are  for  the  most  part  less  tangible  than  the 
local  causes  of  ])redisposition. 

Organs  and  parts  of  tlic  body  may  inherit  special  vulnerability  to 
certain  infections.  Susce[)til)ility  to  certain  infectious  diseases  may  be 
manifest  in  races  and  families.  The  negro  race  is  less  susceptible  to 
yellow  fever  than  the  white.  Algerian  sheep  are  in  large  measure  insus- 
ceptible to  anthrax,  which  is  very  fatal  to  other  sheep.  Black  rats  are 
more  resistant  than  gray,  and  gray  rats  more  resistant  than  white,  to 
anthrax  (IMiillcr). 

Age  intlueiK'es  predisposition,  as  regards  some  infectious  diseases  favor- 
ably, as  regards  others  unfavorably.  Wounds  in  children,  as  a  rule, 
heal  more  (juickly,  and  with  less  danger  of  suppuration  should  pyogenic 
bacteria  enter,  than  in  old  jjcople.  Certain  infectious  diseases  are  most 
common  in  infancy,  otliers  in  adolescence  or  in  maturity  or  in  old  age. 
Osteomyelitis  is  nuich  more  common  in  eiiildren  than  in  adults.  This 
has  been  attributed  to  the  predisposing  influence  of  injuries  to  which 
children  are  more  liable.  Doubtless  injuries  enter  into  the  causation  as 
a  predisposing  factor,  but  it  has  been  shown  experimentally  that  there  is 
a  special  susceptibility  of  the  bone-marrow  of  young  growing  animals  to 
infection  by  jn'ogenic  cocci  injected  into  the  circulation  (Rodet,  Colzi, 
Courmont  and  .Taboulay,  Tvannclongue  and  Achard,  Lexer).  In  labora- 
tory experiments  young  animals,  as  a  rule,  are  found  to  be  more  suscept- 
ible to  most  pathogenic  bacteria  than  old  ones.  There  is  a  special  insus- 
ceptibility of  sucklings  during  the  first  months  of  life  to  certain  infectious 
diseases,  such  as  mumps,  measles,  scarlet  fever.     As  will  be  explained 


304       GENERAL  BACTERIOLOGY  OF  SURGICAL  INFECTIONS. 

later,  the  embryo  possesses  remarkable  insusceptibility  to  some  infec- 
tions. 

There  is  no  evidence  that  tiiore  is  any  difFerence  in  predisposition  to 
infection  between  males  and  females,  except  as  regards  infections  directly 
related  to  sexual  functions. 

General  antemia,  induced  by  loss  of  blood,  has  been  shown  experi- 
mentally to  increase  susceptibility  to  infection  with  various  micro-organ- 
isms, including  the  pyogenic  cocci,  Friedliinder's  bacillus,  and  the  an- 
thrax bacillus  (Rodet,  Gartner,  Ghauveau,  and  others).  Operative  and 
other  wounds  arc  more  likely  to  su]ij)urate  when  there  has  been  much 
hemorrhage  than  when  the  loss  of  lilood  is  slight.  In  general,  imjiaired 
vitality  and  nutrition  of  the  body  may  predispose  to  certain  infections, 
including  wound-infection.  More  or  less  plausible  predisposing  causes 
operating  in  this  May  are  bad  and  insufficient  food,  overwork,  depressing 
emotions,  exposure  to  heat  or  cold,  overcrowding,  bad  air,  and,  in  general, 
insanitary  surroundings  and  all  conditions  of  misery. 

A  large  number  of  experiments  ha\e  been  made  upon  animals  to 
determine  the  influence  of  various  factors  in  increasing  susceptibility  to 
infection.  The  results  of  these  experiments  are  interesting  and  suggest- 
ive in  many  ways.  Some  of  them  evidently  correspond  to  conditions 
observed  in  man,  but  it  is  to  lie  remembered  that  without  additional  evi- 
dence we  have  no  right  to  a])ply  the  results  directly  to  human  beings,  or 
to  any  other  bacteria  or  other  animals  than  those  ex]ierimented  with. 
The  more  important  results  of  these  animal  exjoeriments  are  the  fol- 
lowing : 

Prolonged  narcosis  may  imjjair  resistance  to  some  pathogenic  micro- 
organisms. Klein  and  Goxwell  made  frogs  and  rats  highly  susceptible 
to  anthrax  by  narcosis  witli  ether  and  chlorof  )rm,  and  similar  results 
have  been  obtained  with  curare,  alcohol,  chloral,  morphine,  and  upon 
other  animals  and  with  other  diseases.  In  speaking  of  the  effect  of 
antesthetics  in  predisposing  to  wound-infection  Eoswell  Park  '  says : 
"  There  is  good  reason  to  think  that  chloroform  and  etlier  administered 
for  some  time  may  produce  such  changes  in  the  blood  and  tissues  that 
vital  processes  of  repair,  cell-resistance,  and  chemotaxis  may  be  so  far 
interfered  Mith  as  to  facilitate  subsequent  infection." 

Feser,  Hankin,  and  Miiller  found  that  rats  fed  on  bread  are  more 
susceptible  to  anthrax  than  those  fed  on  meat.  Miiller  observed  the 
same  degree  of  insusceptibility  when  the  extractive  substances  from  meat 
were  fed. 

Canalis  and  Morpurgo,  and  Sacchi  rendered  pigeons  highly  suscept- 
ible to  anthrax  by  hunger,  and  Bouchard  noted  the  lowering  or  disap- 
pearance of  artificial  immunity  in  rabbits  from  anthrax  by  starvation. 
Prolonged  abstinence  from  water  was  observed  by  Pernice  and  Alessi 
to  render  relatively  insusceptible  animals  more  susceptible  to  anthrax. 
Charrin  and  Roger  found  in  fatiy-ue  induced  bv  working  a  treadwheel 

.  .  ...  * 

a  factor  which  increased  the  .suscc])tibility  of  rats  to  anthrax  and  symp- 
tomatic anthrax. 

Various  chemical  substances  introduced  into  the  body  may  increase 
susceptibility  to  certain  infections.  Gottstein  and  Mya  and  Sanarelli 
have  shown  that  poisons,  such  as  chlorates,  pyrogallic  acid,  pyridin, 

'  Park,  loc.  cit. 


CONDITIONS  FAVORING  THE  DEVELOPMENT  OF  INFECTIONS.    305 

■whifli  destroy  red  blood-corpuscles,  may  render  insusceptible  animals 
highly  susceptible  to  certain  pathogenic  micro-organisms,  although  hse- 
matolysis  thus  produced  in  the  case  of  some  animals  and  certain  micro- 
organisms did  not  weaken  natural  immunity.  Bonome  found  tliat 
luematolysis  and  hajmoglobinuria  causeil  by  injection  of  water  into  the 
circulation  of  rabbits  lessened  the  bactericidal  power  of  the  blood  as 
regiirds  the  staphylococcus  aureus.  By  feeding  w'hite  mice  with  phlor- 
idzin,  which  j)roduces  glycosuria,  Leo  i-endered  these  animals  highly 
susceptible  to  glanders,  from  whicli   normally  tliey  are  immune. 

Tlie  most  important  class  of  experiments  showing  the  predisposing 
influence  of  certain  chemical  substances  upon  infection  are  those  in  wliich 
various  ferments  and  bacterial  products  have  been  used.  In  considering 
bacterial  association  (page  291)  attention  has  already  been  called  to  the 
fact  that  the  chemical  products  of  some  bacteria  favor  the  development 
of  infection  with  other  bacteria.  The  susceptibility  of  an  animal  to 
infection  witli  a  specific  micro-organism  can  often  be  increased  by  the 
preliminary  or  simultaneous  injection  of  the  products  of  the  organism. 
It  is  not  only  the  products  of  jjathogenic  bacteria  which  may  thus 
increase  susceptibility,  but  also  those  of  certain  saprophytic  varieties, 
particularly  of  the  ordinary  putrefactive  bacillus  proteus.  Nor  is  it 
necessary  that  tlie  bacterial  products  in  order  to  weaken  resistance  to 
infection  sliould  cause  distinct  toxic  symptoms.  We  do  not  possess  any 
satisfactory  experimental  evidence  that  the  volatile  and  stinking  products 
of  putrefactive  decomposition  augment  susceptibility  to  infection. 

Park,  Bouchard,  and  others  lay  much  emphasis  upon  auto-intoxication 
from  absorption  of  fermentative  products  in  the  stomach  and  intestine  as 
a  [ircdisposiug  cause  of  infection,  ])articularly  with  the  pyogenic  cocci. 
Neumann  and  Canon,  in  order  to  test  the  predisposing  influence  of 
absorption  of  fermentative  products  from  tlie  intestine,  ligated  aseptically 
the  small  intestine  of  rabbits  near  the  ileo-csecal  valve  and  injected  sub- 
cutaneously  a  streptococcus  culture.  The  animals  with  intestinal  obstruc- 
tion, with  few  exceptions,  died  with  streptococcus  septic£emia,  whereas 
the  streptococci  injected  into  normal  rabbits  produced  only  local  inflam- 
mation at  the  point  of  injection.  The  ligation  of  the  intestine  close  to 
the  stouiach  was  not  followed  by  generalization  of  the  stre]>tococcus 
infection.  So  deadly  an  operation  as  ligation  of  the  intestine  introduces 
so  many  other  factors  than  the  possible  absorption  of  poisonous  intestinal 
products  that  these  experiments  caimot  be  considered  to  prove  what  they 
were  intended  to  demonstrate.  Extirpation  of  the  kidneys,  with  sub- 
cutaneous injection  of  streptococci,  also  leads  to  general  streptococcus 
infection. 

That  many  acute  and  chronic  diseases  lower  the  resistance  of  the  body 
to  pathogenic  micro-organisms  has  repeatedly  been  mentioned  in  the 
course  of  this  article,  and  is  universally  admitted.  The  influence  of 
certain  infectious  diseases  in  favoring  the  development  of  secondary  and 
mixed  infections  has  been  sufficiently  i-efcrred  to. 

Diabetes  mellitus  is  well  known  to  increase  in  a  marked  degree  the 
susceptibility  to  infection,  particularly  with  pyogenic  cocci  and  the 
tubercle  bacillus.  Among  other  diseases  characterized  by  lessened  resist- 
ance to  infection  may  be  especially  mentioned  acute  and  chronic  Bright's 
disease,    arterio-sclerosis,    cardiac  disease,  alcoholism,  syphilis,  rickets, 

Vol.  1—20 


306       GENERAL  BACTERIOLOGY  OF  SURGICAL   IXFECTIONS. 

sciu'vv,  leucocythsemia,  Hodgkin's  disease.  All  (if  these  diseases  are 
prone  to  lessen  resistance  to  pyogenic  cocci,  and  especially  to  the  strep- 
tococcus pyogenes.  A  localized  streptococcus  infection  is  much  more 
likely  to  become  generalized  when  it  develops  in  persons  affected  \\ith 
any  of  these  diseases  than  when  it  appears  in  a  previously  healthy 
person.  Here  also  attention  may  be  called  to  the  terminal  strepto- 
coccus septicaemias  occurring  in  Bright's  disease,  heart  disease,  and 
various  chronic  diseases.  They  may  not  be  distinguished  by  character- 
istic symptoms  during  life,  and  are  to  be  ranked  among  such  events  as 
terminal  pneumonia  and  dysentery.  The  portal  of  entry  is  most  fre- 
quently the  lungs,  skin,  and  intestine. 

Of  218  autopsies  of  chronic  Bright's  disease,  general  arterio-sclerosis, 
and  chronic  heart  disease  at  the  Johns  Hopkins  Hospital,  in  154  there 
were  definite  infectious.  Of  .32  cases  of  local  streptococcus  infection, 
excluding  perforative  peritonitis,  tabulated  from  the  autopsy  records  of 
the  hospital  by  the  writer,  chronic  nephritis,  general  arterio-sclerosis,  or 
chronic  heart  disease  was  present  in  18.  In  11  out  of  14  cases  of  general 
streptococcus  infection  one  or  more  of  these  diseases  was  present.  We 
have  observed  several  cases  of  general  streptococcus  infection  in  Icuco- 
cytha?mia  and  Hodgkin's  disease. 

In  a  large  number  of  cases  we  are  able  to  find  no  explanation  of  the 
existence  of  individual  predisposition. 

In  conceding  to  predisposition  its  full  importance  as  a  factor  in  the 
etiology  of  surgical  infections,  we  are  not  to  forget  that  pyogenic  cocci 
occur  of  such  virulence  that  they  can  readily  overcome  the  natural  resist- 
ance of  the  most  insusceptible  human  being. 

FcETAL  Infection. 

The  embr}-o  may  be  infected  by  transmission  of  the  specific  micro- 
organism with  the  ovum  or  semen.  The  only  example  of  this  germinal 
infection  in  which  the  conditions  are  thoroughly  understood  is  jiebrine 
of  silkworms  caused  by  sporozoa,  which  have  been  studied  in  all  stages 
of  transit  through  the  ovum  and  si)ermatozoa  to  the  infected  offspring. 

The  only  infectious  disease  of  human  beings  which  has  been  proven 
to  be  capable  of  conveyance  to  the  offspring  through  the  ovum  or 
spermatozoa  is  syphilis.  Congenital  syphilis  is  usually  due  to  germinal 
infection,  and  it'may  come  from  either  a  syphilitic  father  or  a  syphilitic 
mother. 

Intra-uterine  or  placental  infection  of  the  foetus  may  occur  in  many 
infectious  diseases.  Although  the  intact  placenta  is  a  perfect  jihysiologi- 
cal  filter,  which  does  not  permit  the  passage  of  inanimate  particles  from 
the  blood  of  the  mother  to  that  of  the  foetus,  nevertheless  pathogenic 
micro-organisms  are  capable  of  breaking  through  this  barrier.  The 
conditions  Avhich  permit  the  passage  of  micro-organisms  from  mother  to 
foetus  can  sometimes  be  demonstrated  in  the  form  of  definite  lesions  of 
the  placenta,  either  pre-existing  or  caused  by  the  specific  micro-organ- 
isms or  their  products.  Circulatory  disturbances,  hemorrhages,  defects 
in  the  epithelium  covering  the  chorion  villi,  areas  of  necrosis,  and  tuber- 
cles in  the  placenta  have  been  observed  with  more  or  less  frequency  in 
cases  of  fa?tal  infection,  but  often  no  placental  lesion  could  be  detected. 


F(ETAL  INFECTION.  307 

In  the  later  stages  of  pregnancy  and  during  parturition  the  anatomical 
and  physiological  conditions  would  seem  to  be  more  favorable  for  the 
escape  of  micro-organisms  from  the  mother's  blood  to  the  foetus  than 
in  the  early  stages. 

Some  micro-organisms  are  much  better  adapted  than  others  to  pass 
through  the  placenta  from  mother  to  fcetus.  In  animals  the  bacilli  of 
chicken  cholera  and  of  symptomatic  anthrax  and  the  pyogenic  cocci 
frequently  make  this  passage.  Although  there  has  been  much  contro- 
versy as  to  anthrax,  it  is  now  settled  that  anthrax  bacilli  often  pass  from 
mother  to  fa^tus,  but  generally  in  such  small  numbers  and  without  sub- 
secpient  multijilication  in  the  fcetus  as  to  require  special  methods  and 
careful  search  for  their  detection. 

In  human  beings  infection  of  the  fwtus  in  utero  has  been  observed 
in  small-pox,  measles,  scarlet  fever,  relapsing  fever,  syphilis,  tuberculosis, 
croupous  pneumonia,  typhoid  fever,  anthrax,  and  affections  caused  by 
pyogenic  cocci.  In  general,  such  infection  is  exceptional,  but  in  some 
diseases  it  is  comparatively  common.  Surgical  importance  attaches  to 
the  fact  that  both  experiments  on  animals  and  clinical  observations  show 
that  the  pyogenic  cocci  are  frequently  transmitted  to  the  fcetus  from  an 
infected  mother. 

Developed  tuberculosis  in  the  new-born  infant  is  extremely  rare, 
although  it  has  been  observed,  but  this  rarity  does  not  prove  that  tubercle 
bacilli  may  not  often  be  transmitted  from  mother  to  foetus.  It  takes 
time  and  susceptibility  for  tubercle  bacilli  to  produce  recognizable 
lesions.  Tubercle  bacilli  without  developed  tuberculosis  have  been 
repeatedly  found  in  the  fcetus  of  tuberculous  mothers.  Birch-Hirschfcld 
detected  in  a  seven-months'  fcetus,  removed  by  Cfesarean  section  from  a 
mother  with  acute  miliary  tuberculosis,  tubercle  bacilli  both  by  micro- 
scopical examination  and  by  inoculation  of  guinea-pigs.  There  were  no 
tuberculous  lesions  in  the  fcetus.  The  failure  to  find  tubercle  bacilli  in 
a  large  number  of  similar  cases  can  hardly  be  regarded  as  proof  of  their 
absence,  when  one  considers  the  difficulty  of  demonstrating  tubercle 
bacilli  in  small  number  irregularly  distributed  through  a  large  mass 
without  any  lesion  to  indicate  where  they  are  most  likely  to  be  found. 
Gartner  finds  that  the  transmission  of  tubercle  bacilli  from  mother  to 
fcetus  is  common  in  the  experimental  tuberculosis  of  mice,  rabbits,  and 
canary  birds. 

There  is  reason  to  believe  that  the  embryo  offers  great  resistance  to 
the  growth  of  tubercle  bacilli.  Maffucci  has  found  that  tubercle  bacilli 
inoculated  into  hens'  eggs  before  incubation  remained  quiescent  during 
the  period  of  embryonic  development,  but  caused  the  death  of  most  of 
the  chicks  from  tuberculosis  in  three  weeks  to  four  and  a  half  months 
after  birth.  We  have  evidence  tnat  in  human  beings  living  and  virulent 
tubercle  bacilli  may  remain  latent  in  the  body  a  long  time.  As  already 
mentioned,  the  chances  of  penetration  of  bacilli  into  the  fcetus  appear 
to  be  more  favorable  during  the  later  period  of  pregnancy  than  earlier. 
The  frequency  of  tuberculosis  increases  very  rapidly  with  each  succeeding 
■week  after  birth,  until  during  the  second  half  of  the  first  year  and  during 
the  second  year  of  life  fotal  tul)erculosis  is  very  common,  and  then 
becomes  less  frc-quent  until  after  jniberty.  Infantile  tuberculosis  is  far 
more  commonly  situated  in  internal  organs,  such  as  the  lymphatic  glands, 


308       GENERAL   BACTERIOLOGY  OF  SURGICAL  INFECTIONS. 

meninges,  bones,  and  joints,  without  tiil)ercnions  lesion  on  ;niv  exposed 
surface  of  the  body,  tlian  is  tulxrcuiusis  (if  adults. 

Tiiese  are  the  arguments  wiiich  are  urged  Ijy  IJauingarten  and  others 
with  great  force  in  favor  of  frequent  bacillar  heritage.  The  majority  of 
autiiorities,  however,  are  rehictant  to  abandon  the  older  views,  and  the 
final  settlement  of  this  important  question  involves  great  difficulties  not 
likely  to  be  soon  overcome. 

The  portal  of  entry  to  the  fcetus  is  the  umbilical  vein,  and  therefore 
micro-ortjanisras  wtiuld  be  carried  first  to  the  liver  and  the  ritjht  side  of 
the  heart.  Corresponding  to  this,  we  find  that  lesions  of  the  liver  and 
of  the  right  side  of  the  heart  are  particularly  common  in  congenital 
infections.  Pyogenic  cocci,  as  already  mentioned,  break  through  the 
placental  barrier  with  comparative  ease,  and  these  are  the  bacteria  most 
often  associated  with  endocarditis,  which  is  more  common  on  the  right 
side  of  the  heart  in  the  foetus  and  new-born  than  in  the  adult. 

Although  the  foetus  may  react  to  pathogenic  micro-organisms  in  the 
same  way  as  the  mother,  or  even  more  severely,  it  possesses  a  remarkable 
insusceptibility  to  some  infections,  as  has  been  proven  experimentally 
and  clinically.  There  are  several  instances  in  which  the  specific  bacteria 
of  cn)upous  pneumonia  and  of  typhoid  fever  have  been  found  in  the 
stillborn  embryos  of  mothers  affected  with  these  diseases,  but  there  is  no 
satisfactory  recorded  instance  of  an  infant  born  with  the  lesions  of 
typhoid  fever  or  those  of  lobar  pneumonia  caused  by  the  pneumococcus. 
Some  bacteria  which  cause  localized  infections  in  the  mother  may  pro- 
duce in  the  toetus  general  septicemia  without  localizations. 

General  Considerations  concerning  Pyogenic  Bacteria. 

The  pyogenic  bacteria  play  such  a  predominant  role  in  surgical  in- 
fections, and  their  pathogenic  (;haracters  jjresent  so  many  jieculiarities, 
that  it  is  appropriate  to  consider  here  the  general  relations  of  pyogenic 
bacteria  to  surgical  infections,  although  the  consideration  of  the  special 
diseases  caused  by  these  bacteria  does  not  fall  within  the  scope  of  this 
article. 

There  are  no  specific  bacteria  of  suppuration.  On  the  one  hand  the 
number  of  bacteria  which  under  special  conditions  are  capable  of  causing 
suppurative  inflannnation  is  large,  and  is  not  limited  to  any  particular 
group,  and  on  the  other  hand  the  bacteria  which  are  most  fre(|Uently  the 
cause  of  suppuration  are  capable  of  causing  other  forms  of  infiammation 
and  of  producing  infection  without  inflammation. 

Certain  staphylococci  and  streptococci,  however,  are  found  in  jnirulent 
inflammations  in  human  beings  so  much  more  frequently  than  other 
micro-organisms  that  they  are  the  ])yogenic  bacteria  par  e.i-ccllence,  and 
are  the  ones  generally  understood  when  the  expression  "  micro-organisms 
of  pus"  or  "  pvogenic  bacteria"  is  used  without  any  qualification.  These 
staphylococci  and  streptococci  are  endowed  with  pus-producing  properties 
in  larger  measure  than  are  other  bacteria,  and  of  all  their  pathogenic 
effects  the  production  of  suppurative  inflammation  is  the  most  promi- 
nent. 

The  most  connnon  pyogenic  cocci  are  the  staphylococcus  pyogenes 
aureus,  the  streptococcus   pyogenes,  and    the    staphylococcus   pyogenes 


CONSWERATIOXS  CONCERNING  PYOGENIC  BACTERIA.        309 

albus,  including  the  staphylococcus  epiderniidis  albus.  In  the  second 
rank,  as  regards  both  fretiuencv  and  virulence,  arc  tlic  stapliylococcus 
pyogenes  citreus,  the  staphylococcus  cereus  allnis,  and  the  staphylococcus 
cereus  flavus.  More  common  and  far  more  important  than  the  cocci  of 
the  latter  group  are  the  micrococcus  lanceolatus  and  the  micrococcus 
gonorrhoese.  Although  these  are  not  always  ranked  among  the  pyogenic 
cocci  in  the  restricted  sense,  they  are  genuine  pus-producers.  The 
micrococcus  tetragenus  septicus  is  rarely  the  sole  cause  of  suppuration. 
The  status  of  the  micrococcus  pyogenes  tenuis  is  uncertain.  It  is  per- 
haps identical  with  the  micrococcus  lanceolatus. 

There  is  a  long  list  of  bacilli  wdiich  have  been  shown  with  greater  or 
less  certainty  to  be  capable  of  producing  suppurative  inflammations  in 
man.  The  principal  ones  arc  bacillus  pyogenes  fietidus,  bacillus  coli 
communis,  bacillus  typhi  abduniinalis,  bacillus  tuberculosis,  bacillus 
pyocyaneus,  bacillus  pneumoni;e  of  Friedlander,  bacillus  proteus.  Acti- 
nomyces belongs  to  the  class  of  schizomycetes  and  is  a  pus-producer. 

Several  anaerobic  bacilli  have  been  found  both  in  pure  culture  and 
associated  Avith  other  bacteria  in  closed  abscesses.  Of  these  may  be 
especially  mentioned  bacillus  ])hlcgmones  emphysematosa;  of  E.  Fraeidvcl, 
which  is  j)robably  identical  witli  bacillus  aerogenes  capsulatus  previously 
described  by  Welch  and  Xuttall,  and  which  occurs  in  some  phlegmons 
containing  gas. 

The  list  of  demonstrated  pus-producing  bacteria  is  by  no  means  ex- 
hausted by  those  enumerated.  In  the  experience  of  the  writer  bacilli 
are  more  common  causes  of  spontaneous  abscesses  in  laboratory  animals 
than  cocci.  A  very  large  number  of  bacteria  are  capable  of  jiroducing 
experimental  abscesses  in  animals. 

It  is  fair  to  say  that  not  all  of  the  bacteria  mentioned  above  are 
recognized  as  pyogenic  for  man  by  all  authorities,  and  particularly  that 
some  do  not  so  regard  the  typhoid  bacillus  and  the  tubercle  bacillus ; 
but  in  the  opinion  of  the  writer  their  pyogenic  capacity  has  been  demon- 
strated. 

We  have  very  little  definite  information  as  to  the  underlying  condi- 
tions which  control  the  pyogenic  manifestations  of  such  bacteria  as  the 
typhoid  bacillus,  the  tubercle  bacillus,  and  others  which  do  not  ordi- 
narily cause  purulent  inflammations.  These  conditions  seem  to  pertain 
]>artly  to  the  degree  of  virulence  of  the  micro-organism  and  jiartly  to  the 
local  susceptibility  of  the  tissues  invaded  and  the  general  susceptibility 
of  the  iutlividual.  We  find  in  experiments  upon  animals  that  Ijactcria 
of  weakened  virulence  in  susceptible  animals,  or  those  of 'usual  virulence 
in  insusceptible  animals,  are  prone  to  ])roduce  localized  abscesses.  In 
an  animal  which  has  been  rendered  artificially  immune  from  septicsemia 
caused  by  certain  pathogenic  bai  teria  immunity  is  not  usually  produced 
from  the  develojimcnt  of  local  abscesses  by  tiie  specific  organism,  in  case 
this  is  capable  of  forming  abscesses. 

Statistical  statements  as  to  the  relative  frcfiuency  with  which  the  dif- 
ferent pyogenic  cocci  occur  in  general  in  su])purative  and  septic  aifections 
vary  a(u;ording  to  the  class  of  cases  which  preponderate.  The  staphylo- 
coccus aureus  is  by  far  the  most  conmion  micro-organism  in  furuncles  and 
osteomyelitis,  and  is  common  in  circumscribed  subcutaneous  abscesses. 
The  streptococcus   pyogenes   is   by  far  the  most  ci>mraon  organism  in 


310       GENERAL  BACTERIOLOGY  OF  SURGICAL  INFECTIONS. 

spreading  plegmonous  cellulitis,  inflammations  of  serous  membranes, 
puerperal  infeetions,  and  sojiticremia.  It  is  the  cause  of  erysijiclas  in 
practically  all  cases  of  this  disease.  It  is  a  frequent  cause  of  all  kinds 
of  inflammations  of  the  throat  and  of  broncho-pneumonia.  The  staphylo- 
coccus albus  is  often  associated  with  the  other  p^-ogenic  cocci,  espe- 
cially in  inflammations  involving  the  skin.  It  occurs  most  frequently 
in  the  same  general  class  of  cases  as  the  staphylococcus  aureus.  Al- 
tliough  capable  of  causing  grave  infections,  the  characters  of  the  inflam- 
mations in  which  the  white  staphylococcus  is  found  alone  are  usually 
mild.     Two  or  more  species  of  pyogenic  cocci  are  often  combined. 

The  relative  frequency  of  occurrence  of  the  pyogenic  cocci  seems  to 
vary  somewhat  according  to  the  locality.  Levy  finds  in  Strassburg  the 
staphylococcus  aibus  more  frequently  than  the  staphylococcus  aureus  in 
all  suppurative  aifections  except  furuncles,  and  he  was  unable  to  confirm 
the  usual  statement  that  the  albus  is  less  virulent  than  the  aureus. 

The  following  table  gives  the  results  of  the  bacteriological  examina- 
tion of  135  ambulatory  and  ojierative  surgical  cases  by  Dowd '  in  the 
Vanderbilt  Clinic  and  Cancer  Hospital  in  New  York.  It  affords  a  good 
idea  of  the  relative  frequency  of  the  different  pyogenic  cocci  in  the  chiss 
of  cases  which  most  frequently  come  to  the  attention  of  the  surgeon  : 


Streptococcus  pyogenes  alone 

Streptococcus  pyogenes  predominant 

Streptococcus  pyogenes  relatively  few 

Staphylococcus  pyogenes  aureus  alone 

Staphylococcus  pyogenes  aureus  predominant  .... 

Staphylococcus  pyogenes  aureus  relatively  lew  .... 

Staphylococcus  pyogenes  or  epidermidis  albus  alone   . 

Staphylococcus  pyogenes  or  epidermidis  albus  pre- 
dominant   

Staphylococcus  pyogenes  or  epidermidis  albus  rela- 
tively few 

Staphylococcus  cereus  albus 

Staphylococcus  citreus 

Bacillus  pyocyaneus 

Bacillus  coli  communis 

Very  few  growths  on  agar 

No  growths  on  agar        

Few  undetermined  colonies 


9 
23 

3 
11 

S 

13 
1 


10 
3 
1 


12 


Ha 


6 

1 

1 

3 
3 
3 
11 
6 


The  cases  from  which  no  growth  occurred  were  tuberculous  abscesses 
and  buboes.  8  of  the  51  cases  of  cellulitis  showed  a  persistent  tendency 
to  spreading  inflammation  with  undermining  of  the  ti-ssues.  In  all  of 
these  8  cases  streptococci  were  foinid.  In  2  cases  of  pysemia  staphy- 
lococcus aureus  and  streptococci  were  present  in  the  original  woiuid,  but 
onl}'  streptococci  in  the  metastases. 

It  is  interesting  to  contrast  with  these  results  of  the  examination 

'  Charles  X.  Dowd,  "Some  Considerations  on  Different  Types  of  Exudative  Inflam- 
mation," Medical  Recurd,  Xew  York,  Sept.  S,  1894. 


CONSIDERATIONS  CONCERNING  PYOGENIC  BACTERIA.        311 

of  ambulatory  and  operative  surgical  cases  the  results  of  the  bacterio- 
l(igical  examination  of  post-mortem  cases.  In  about  500  autopsies  at 
the  Johns  Hopkins  Hospitiil  there  were  found  in  185  cases  the  follow- 
ing bacteria : 

Number  of 
cases. 

Bacillus  coli  communis i^o 

Streptococcus  pyogenes 62 

Staphylococcus  pyogenes  aureus 43 

Micrococcus  lanceolatus 29 

Staphylococcus  pyogenes  albus _ 14 

Bacillus  typhosus,  as  the  cause  of  special  complications 7 

Bacillus  pyocyaneus S 

Proteus 4 

Micrococcus  tetragenus 2 

Staphylococcus  pyogenes  citreus 1 

Pneumobacillus  of  Friedliinder      1 

Bacillus  pyogenes  fietidus 3 

Bacillus  aerogenes  capsulatus  ....        3 

Undetermhied  bacteria 35 

The  streptococcus  cases  do  not  include  those  in  which  streptococci 
were  found  only  in  phthisical  cavities  or  adjacent  lung.  The  cases  with 
micrococcus  lanceolatus  are  tliose  in  Avhich  this  organism  was  found 
without  pneumonia  or  as  the  cause  of  some  e.xtra-thoracic  complicatioia 
of  pneumonia.  No  cases  are  included  in  which  the  bacteria  were  found 
simply  on  e.xpo.sed  surfaces  of  the  body.  Among  the  undetermined  bac- 
teria are  several  interesting  pathogenic  forms  which  could  not  be  posi- 
tively identified  with  species  already  described.  Mention  has  already 
been  made  of  the  frequent  invasion  of  the  colon  bacillus  without  any 
pathogen ic  manifestations. 

The  preceding  table  is  inserted  not  with  the  intention  of  analyzing 
in  this  article  the  cases '  composing  it,  but  to  show  the  great  differences 
l)ctween  the  results  of  the  bacteriological  study  of  living  surgical  cases 
and  those  of  the  antop.sy  material  of  a  general  hospital,  and  especially 
to  emphasize  the  preponderance  of  streptococcus  cases  over  staphylo- 
coccus and  all  other  pyogenic  cases  in  such  material. 

All  of  the  affections  caused  by  one  species  of  the  pyogenic  cocci  may 
l)e  caused  bv  anv  of  the  others.  For  example,  the  staphylococcus  aureus 
may  produce  spreading  phlegmons,  infiaTumations  of  serous  membranes, 
puerperal  infections,  general  scptica^niia  as  well  as  the  streptococcus  pyo- 
genes, and  the  streptococcus  pyogenes  may  cause  circumscribed  abscesses 
and  osteomyelitis  as  well  as  the  yellow  or  white  staphylococcus.  Jordan 
claims  that  the  staphyh^coccus  aureus  may  cause  erysi jielas,  but  Petruschky 
does  not  regard  his  observations  on  this  point  as  conclusive. 

J^^U'thermore,  these  pyogenic  staphylococt'i  and  streptococci  may  cause 
all  kinds  of  iuHammation  besides  tiie  suppurative.  Tiiey  may,  and  often 
do,  cause  serous,  sero-fibrinous,  and  fibrinous  inflammations  of  serous 
membranes.  The  streptococcus  pyogenes  may  cause  catarrhal  and 
fibrinous  inflammations  of  mucous  membranes.  Pyogenic  cocci  may  be 
the  cause  of  simple  inflanniiatory  (edema  or  serous  infiltration  of  the 
tissues.  They  are  sometimes  found  in  cutaneous  vesicles  and  blebs 
containing  clear  serum.     They  may  be  the  sole  organisms  present  when 

'  The  analysis  of  these  cases  was  the  sul'ject  of  the  Middleton  Goldsmith  lecture  by 
the  writer  in  .Vpril,  1S94  {Tmiui.  N.  Y.  I'athulwjical  Society  for  1894). 


312       GENERAL  BACTERIOLOGY  OF  SURGICAL  INFECTIONS. 

the  inflammatory  exudate  is  heinorrhajjic.  Tlicy  may  produce  exten- 
sive nocrosis  of  tlic  tissues  witli  scarcely  any  infiammatory  exudate.  We 
find  tlie  same  sta])hyl()C(K'ci  and  streptococci  in  tliose  rarer  forms  of 
osteomyelitis  which  do  not  suppurate  as  in  the  ordinary  sup]>nrative 
form.  They  are  the  usual  cause  of  periostitis  and  ostitis  alhuminosa, 
in  A\hich  the  exudate  is  serous.  A  serous  or  sero-fibrinous  inflannua- 
tion  caused  by  pyogenic  cocci  may  be  transformed  into  a  purulent  one 
without  the  appearance  of  any  new  species  of  micro-organism. 

We  cannot  at  present  give  any  satisfact(jry  explanation  of  these 
diverse  effects  produced  by  one  and  the  same  bacterial  sjiecies.  We 
seek  to  exjtlain  these  differences  usually  by  referring  to  such  factors  as 
the  degree  of  virulence  of  the  organism,  the  manner  of  its  invasion,  the 
site  of  infection,  and  the  condition  of  the  patient.  Variations  in  viru- 
lence and  the  general  condition  of  the  jiatieut  cannot  be  the  sole  explan- 
ation, for  these  pyogenic  cocci  may  in  tiie  same  individual  cause  a  sup- 
])urative  inflanunation  in  one  part  of  the  bodv  and  a  serous  or  a 
sero-fibrinous  inflammation  in  another  part,  without  any  bacteriological 
difference.  We  have  observed  this  in  some  instances  of  multiple  sero- 
sitis,  and  Schrank  has  reported  a  case  in  which  periostitis  ali)urainosa 
was  associated  with  suppurative  osteomyelitis  in  the  same  tibia.  The 
same  micro-organisms,  staphylococci  and  streptococci,  were  jiresent  in 
the  exudate  in  both  situations.  They  had  produced  pus  in  the  bone- 
marrow  and  a  simple  serous  exudate  between  the  periosteum  and  bone. 
The  deciding  factor  must  have  been  in  the  tissues,  and  not  in  the  micro- 
organisms or  the  general  predisposition  of  the  individual,  and  this  same 
factor,  the  specific  character  of  the  tissues,  little  as  we  may  comprehend 
its  nature,  is  doubtless  the  explanation  of  their  varying  reactions  to  the 
same  infectious  agents  in  many  other  cases — a  point  which  has  been 
justly  emphasized  by  Kurt  Jliillcr. 

It  might  be  inferred  from  what  has  been  said  as  to  the  interchange- 
able effects  produced  by  the  different  pyogenic  cocci  that  no  diagnostic 
or  prognostic  imjwrtance  is  to  be  attached  to  the  determination  of  the 
particular  species  of  pyogenic  coccus  present.  If  the  streptococcus  can 
do  everything  which  the  sta]>hylococci  can  do,  if  each  s])ecies  can  pro- 
duce mild  as  well  as  grave  infections,  it  is  argued  by  some  that  it  is  of 
no  practical  importance  to  determine  what  particular  micro-organism  is 
present  in  a  given  case. 

It  is  more  important  for  the  surgeon  to  understand  the  general  rela- 
tions of  bacteria  to  traumatic  and  other  jn'ogenie  infections  than  to  become 
familiar  with  the  special  characters  of  the  individual  micro-organisms 
which  cause  these  infections,  and  therefore  the  principal  part  of  this  arti- 
cle has  been  devoted  to  a  consideration  of  these  general  relations.  But 
apart  from  the  interest  which  pertains  to  the  study  of  all  asjiects  of 
disease,  even  those  without  evident  practical  bearings,  it  would  be  a 
mistake  to  suppose  that  the  bacteriological  examination  of  infectious 
processes  caused  by  pyogenic  cocci  is  devoid  of  value  for  diagnosis,  prog- 
nosis, or  treatment. 

There  are  certain  general  rules  as  to  the  characters  of  the  infections 
most  likely  to  be  produced  by  the  different  species  of  pyogenic  cocci,  and 
as  to  the  probability  of  finding  a  given  species  in  a  certain  kind  of  infec- 
tion.    It  would  lead  too  far  to  attempt  to  consider  here  all  the  differ- 


COySIDEEATIOA^S  CONCEBNmO  PYOGENIC  BACTERIA.        313 

ent  surgical  infections  with  reference  to  these  points.  A  few  illustrative 
examples  may  be  cited. 

The  white  staphylococcus  causes  severe  local  and  general  infections  so 
infreiiueutly,  at  least  in  this  country  so  far  as  we  are  informed,  that  the 
recognition  of  its  exclusive  presence  in  an  inflamed  external  part  of  the 
body  justifies  the  probable  conclusion  that  the  inflammation  will  pursue 
a  mild  course  and  bo  readily  amenable  to  treatment. 

The  streptococcus  pyogenes  may  possess  all  degrees  of  virulence. 
Although  a  streptococcus  coming  from  a  case  of  erysipelas  or  puerperal 
fever  may  not  be  distinguisiicd  botanically  from  a  streptococcus  coming 
from  a  liealthy  mucous  membrane  or  caught  from  the  air,  it  is  a  very 
different  thing  in  its  possibilities  for  infection.  The  streptococcus  py- 
ogenes, for  niore  frequently  than  other  bacteria,  causes  s.jjreading  phleg- 
monous inflammations  and  grave  forms  of  septicemia.  The  importance 
and  the  frc(picncy  of  streptococcus  septicaemias  accompanying  tuberculosis, 
diphtheria,  typhoid  fever,  scarlet  fever,  the  jiuerperal  state,  erysipelas, 
cellulitis,  and  traumatic  infections  are  probably  not  even  yet  sufficiently 
appreciated  by  physicians  and  surgeons,  notwithstanding  the  rapid  exten- 
sion of  our  knowledge  of  this  subject  in  recent  years.  Septicemias  pro- 
duced bv  other  pyogenic  cocci  under  these  circumstances,  although  they 
may  be  of  equal  "severity  and  similar  character,  are  in  a  small  minority. 

In  view  of  the  fearful  pathogenic  possil)ilities  with  which  streptococci 
may  be  endowed,  a  surgeon  cannot  regard  the  presence  of  these  micro- 
organisms in  a  wound  or  inflamed  part  with  as  little  concern  as  he  may 
the  white  or  even  the  yellow  staphylococcus,  although  it  may  be  that  the 
particular  streptococcus  in  question  is  of  relatively  slight  virulence.  If 
his  patient  have  chronic  Bright's  disease  or  general  arterio-sclerosis  or 
chronic  cardiac  insufficiency,  tiie  anxiety  of  the  surgeon  will  be  increased. 
Intlanunations  of  external  parts  produced  by  staphylococci  are  in  general 
more  amenable  to  treatment  and  rccpiire  less  vigorous  interference  than 
those  caused  by  streptococci.  Streptococcus  cases  are  in  general  more 
dangerous  to  other  surgical  patients  in  their  proximity  than  staphylo- 
coccus cases,  and  are  therefore  more  likely  to  require  isolation. 

The  gravest  staphylococcus  infection  with  which  the  surgeon  has 
commonly  to  deal  is  acute  osteomyelitis.  In  this  particular  field  the 
staphylococcus  aureus  takes  rank  over  the  streptococcus,  although  there 
is  no  specific  micro-organism  of  osteomyelitis  any  more  than  there  is  of 
suppuration  in  general.  Osteomyelitis  may  be  caused  by  the  strejito- 
ooccus  pyogenes  and  other  jnogenic  bacteria,  but,  although  these  other 
bacteria  not  infrotpiently  cause  periostitis,  they  are  very  rarely  the  cause 
of  tnicomplicated  suppurative  osteomyelitis. 

The  especial  conditions  under  which,  in  cases  of  infection  caused  by 
pyogenic  cocci,  the  cocci  apjiear  in  the  blood  in  sufficient  number  to  be 
demonstrable  by  our  methods  of  examination  are  far  from  clear.  We 
find  tiiem  far  more  frequently  in  the  blood  at  autopsies,  even  very  fresh 
ones,  than  we  are  able  to  do  during  life.  Tiie  ])yogenic  cocci,  like  most 
l)athogenic  bacteria,  only  excejitiniially  are  able  to  multi]dy  in  the  cir- 
culating blood  of  human  beings.  The  greater  frc(picncy  of  their  presence 
in  demonstrable  number  at  autopsy  may  be  due  in  part  to  their  multi- 
jjlication  after  death,  but  this  cannot  be  the  sole  explanation,  as  the  cocci 
are  found  in  autopsies  made  very  early  after  death  more  frequently  than 


814       GENERAL  BACTERIOLOGY  OF  SURGICAL   INFECTIONS. 

they  are  found  diirinii'  lifV.  T\w  cxphiiiation  is  probably  that  during  the 
last  liours  of  life  they  often  tind  suitable  conditions  for  their  multiplica- 
tion in  the  blood.  A  similar  phenomenon  can  often  be  observed  in 
inoculated  animals.  All  bacteria,  includiufi;  those  of  the  typical  septi- 
ctemias  of  animals,  such  as  the  bacillus  of  rabbit  sejitica'mia,  of  anthrax, 
the  micrococcus  lanceolatus,  injected  into  the  blood  (piickly  disupjicar 
from  the  circulation.  The  pathogenic  forms  grow  outsiile  of  the  circula- 
ting blood,  and  often  do  not  make  their  rca])pearancc  in  any  considerable 
number  in  the  circulation  until  shortly  before  death  and  after  the  mani- 
festation of  grave  constitutional  syni|)toms.  This  is  true  of  pneumo- 
coccus  septiciemia,  anthrax,  and  other  typical  septicicniias  of  animals. 

In  examining  the  blood  of  living  patients  for  pyogenic  cocci  a  few 
drops  of  blood  do  not  generally  suffice,  as  the  cocci  are  rarely  so  numer- 
ous as  to  be  detected  thus.  The  blood  is  obtained  by  wet  cups  by 
Petruschky,  who  has  developed  a  special  technique  for  these  examina- 
tions. To  the  demonstrations  of  the  white  staphylococcus  in  blood  with- 
drawn by  cutting  or  pricking  the  skin,  which  have  been  made  by  a 
number  of  investigators,  the  writer  attaches  no  diagnostic  significance, 
for  reasons  which  have  been  stated.  The  detection  <jf  streptococci  is 
significant.  Petruschky  and  Canon  found  streptococci  in  the  blood 
during  life  in  a  number  of  cases  of  pytemia,  septicEemia,  and  localized 
infection.  They  were  more  likely  to  be  present  in  severe  than  in  the 
milder  cases,  but  they  were  occasionally  found  in  cases  which  recovered, 
and  even  in  very  mild  infections.  Cocci  arc  found  in  the  blood  in  cases 
both  with  and  without  metastases. 

Doubtless  jjyogonic  cocci  often  enter  the  circulation  in  small  number 
from  a  localized  focus  of  inflammation  caused  by  them.  They  are  often 
disposed  of  without  doing  any  harm  by  the  bactericidal  cells  and  fluids. 
Their  fate,  however,  is  not  always  one  which  is  so  advantageous  to  the 
patient.  They  may  lodge  and  grow  in  internal  parts,  causing  inflam- 
mations of  serous  membranes,  ulcerative  endocarditis,  and  other  meta- 
static inflammations.  They  may  survive,  and  even  multipl)-,  in  the  blood, 
with  or  without  the  production  of  metastases.  These  general  infections, 
particularly  those  with  the  streptococcus  pyogenes,  are  far  more  likely  to 
occur  with  primary  localized  infections,  such  as  erysipelas,  infected 
wounds,  abscesses,  in  persons  with  chronic  Bright's  disease,  and  other 
conditions  which  we  have  repeatedly  specified  as  predisposing  causes, 
than  in  previously  healthy  persons. 

The  usage  has  grown  up  among  bacteriologists  of  limiting  the  name 
"  septicajmia "  to  infections  characterized  by  a  large  multiplication  of 
bacteria  in  the  blood  during  life.  Septicfemias  in  this  bacteriological 
sense  occur  in  man,  l)ut  they  are  not  common.  Far  more  common  are 
cases  of  human  se]5ti«emia  in  which  a  moderate  or  small  number  of 
pyogenic  cocci  are  found  in  the  blood,  but  there  is  no  definite  relation 
between  the  number  of  bacteria  in  the  blood  and  the  character  and 
gravity  of  the  symptoms.  We  cannot  explain  these  symptoms  nor 
some  of  the  lesions  without  assuming  that  they  are  referable  to  the 
action  of  toxic  products  of  the  liacteria,  and  that  these  toxic  products 
may  be  absorbed  from  localized  foci  of  inflanmiation. 

There  are  no  specific  bacteria  of  either  septicaemia  or  pyemia.  The 
same  bacteria  are  found  in  both  diseases. 


BACTERIA   OF  SURGICAL  ISFECTIO^^S.  315 

Bacteria  of  Surgical  Infections. 

The  leading  characters,  especially  tlie  pathogenic,  of  the  bacteria 
concerned  in  surgical  infcetidns  will  here  be  brietly  described.  Cer- 
tain rare  and  unnamed  and  insufficiently  itlentified  bacteria  wliich  have 
been  described  as  occurring  in  surgical  diseases  will  not  be  considered. 

Sfaphi^lococcus  Pyogenes  Aureim  (Plate  II.,  Fig.  5). — Observed  by 
Ogston  (1881),  first  accurately  described  V)y  Becker  (1883),  Ilosenbach 
(1884),  and  Passet  (1885).  Appears  in  the  form  of  spherical  cells, 
averaging  0.8  jul  in  diameter,  which  by  ditferential  staining  often  show 
a  diplococeus  or  biscuit  shape.  Occurs  usually  in  clumps,  also  in  jiairs 
and  short  chains.  May  be  found  both  within  and  outside  of  pus-cells 
in  abscesses.  Stains  readily  with  aniline  dyes,  including  Gram's  stain. 
Forms  an  orange-vellow  pigment,  but  only  in  the  presence  of  free 
oxygen.  Grows  at  ordinary  temperatures,  most  rapidly  at  body  temper- 
ature. Grows  on  all  culture  media  both  with  and  without  free  oxygen. 
Licpiefies  gelatin  rapidly.  Coagulates  milk ;  clouds  bouillon.  May  sur- 
vive in  dried  pus  for  one  hundred  days  ;  is  killed  in  a  much  shorter 
time  by  desiccation  when  contained  in  thin  media.  In  the  moist  con- 
dition is  killed  in  ten  minutes  by  a  temperature  of  58°  C.  (Sternberg). 
When  dried  a  higher  temperature — 1)0-100°  C. — is  required  to  kill  it  in 
a  short  time.  In  bouillon  cultures  all  of  the  cocci  may  be  killed  in  five 
minutes  by  sublimate,  1  :  1000,  but  frequently  some  survive  longer,  even 
uj)  to  thirty  minutes  (Abbott).  Killed  in  a  few  seconds  by  3  per  cent,  car- 
bolic-acid solution.  Virulence  variable.  Pathogenic  properties  for  animals 
and  man  have  already  been  described.  (See  pp.  280,  289,  303,  and  the  pre- 
ceding section,  "  General  Considerations  concerning  Pyogenic  Bacteria."') 

Staplii/locoix-us  Pyogcnett  Albua. — Cultivated  by  Kosenbach  from  pus 
in  1884.  Differs  from  the  aureus  only  by  absence  of  pigment.  As  the 
pigment  may  form  in  aureus  cultures  very  slowly,  the  cultures  should 
be  watched  for  several  days,  up  to  two  weeks,  before  making  a  diagnosis 
of  the  albus.  Pathogenic  effects  similar  to  those  of  the  aureus,  but 
usually  the  virulence  of  the  albus  is  less  than  that  of  the  aureus. 

Sfapliy/ocoeeuii  Epiderinidi'i  Albus  (M\^lch). — Is  probably  only  a  vari- 
ety of  the  staphylococcus  pyogenes  alijus.  Usually  grows  somewhat  more 
slowly ;  liquefies  gelatin  and  coagulates  milk  less  rapidly.  Is  of  little 
virulence  under  ordinary  conditions.  Is  a  regular  inhabitant  of  the  epi- 
dermis, lying  deeper  than  can  be  reached  by  disinfection  of  the  surface  of 
the  skin.    Its  behavior  has  already  been  described  (pj>.  251,  270,  and  272). 

Sfnplii/locoecKs  Pyogenes  Citreiis.—(  "ultivatcd  liy  Passet  from  al:)sccsses 
(1885).  Differs  from  the  aureus  and  albus  only  by  forming  lemon-yellow 
pigment  in  the  presence  of  free  oxygen.  Pathogenic  effects  similar  to 
tiiose  of  the  aureus  and  albus ;  often  of  less  virulence  than  the  aureus, 
but  may  be  highly  virulent.  Is  found  less  frequently  than  the  preceding 
sta])hyl(ic()cci. 

Staphylococci  forming  pigments  intermediate  in  tint  between  the 
aureus  and  citreus  occur,  also  cocci  witli  the  production  of  only  a  very 
faint  yellowish  color,  perhaps  produced  only  after  prolonged  growth. 
This  has  led  Lubinski  and  others  to  the  view  that  these  various  pyo- 
genic staphylococci  are  only  physiological  varieties  of  one  and  the  same 
species. 


316       GENERAL  BACTERIOLOGY  OF  SURGICAL  INFECTIONS. 

iSfaplii/lococcns  Cereus  Alhiix. — Cultivated  from  two  abscesses  by 
Passet  (18<sr)).  Pyofrenic  i>o\voi- not  considered  to  be  demonstrated  by 
Passet  and  Fliigge.  Lew,  liowever,  found  tliis  coccus  in  pure  culture 
in  abscesses  and  other  inflammations,  and  ])roduct'd  su])])urati(in  bv  inoc- 
ulating it  into  the  rabl)it's  eye.  Kesenibles  the  aureus  and  albiis,  but  it 
does  not  liquefy  gelatin  and  it  forms  no  ])ignient. 

The  staphylococcus  cereus favus  was  isolated  by  Passet  in  ])ure  culture 
from  a  chronic  suppurative  periostitis,  but  it  does  not  appear  to  have 
been  found  again  in  abscesses.  Passet  was  unaljle  to  cau.se  abscess  by 
inocadating  it  into  animals.  Diflfers  from  the  staphylococcus  cereus  albus 
only  by  tlie  formation  of  lemon-yellow  pigment. 

Htreplococcas  Pyogenes  ;  tStreptococras  Erysipddtos  (Plate  I.,  Fig.  3). 
— Observed  by  Ogston  in  pus  (1881);  cultivated  by  Fehleisen  from 
erysipelas  (1883),  by  Rosenbach  from  pus  (1884).  The  streptococcus 
of  erysipelas  does  not  ditfer  in  nu)rphology  or  cultural  characters  from 
the  streptococcus  jn'ogenes.  The  same  pathogenic  effects  may  be  pro- 
duced by  each  in  animals  and  in  man,  so  that  the  weight  of  evidence 
is  in  favor  of  the  identity  of  the  streptococcus  ervsipelatos  with  the 
streptococcus  pyogenes,  although  opinions  are  still  di\'ided  on  this 
question. 

The  streptococcus  pyogenes  grows  in  chains  of  variable  length.  The 
individual  cocci  vary  in  size,  .sometimes  in  the  .same  chain.  They  aver- 
age somewliat  larger  than  the  staphylococci.  In  pus  they  occur  in  chains, 
also  in  pairs.  Stain  readily  with  aniline  dyes  and  by  Gram's  method. 
Grow  Avith  or  without  free  oxygen  in  all  ordinary  culture  media.  Most 
stre])tococci  grow  at  room  temperature,  but  more  slowly  than  at  body  tem- 
perature. The  streptococcus  pyogenes  does  not  liquefy  gelatin,  or  does  so 
.slightly  in  some  cases.  Forms  small,  gray,  granular  colonies  on  gelatin 
and  agar.  Grows  invisibly  on  potato,  but  may  grow  visibly.  May  or  may 
not  coagulate  milk  and  cloud  bouillon.  Some  cultures  are  short-lived, 
others  may  live  several  months.  The  streptococcus  jiyogenes  may  survive 
in  dried  pus  for  fourteen  to  thirty-six  days.  Is  killed  in  ten  miiuites  by 
€X])osure  to  54°  C.  (Sternberg).  Is  killed  in  eight  seconds  by  3  per  cent, 
carbolic-acid  solution.  Inoculated  cutaneouslv  into  the  rabliit's  ear,  viru- 
lent streptococci  usually  produce  erysipelas,  from  which  the  animal  recov- 
ers. The  virulence  is  extremely  varialde,  and  is  best  tested  Ijy  inoculating 
mice  into  the  peritoneum,  either  with  the  first  generation  of  a  pure  culture 
or  directly  with  the  blood  or  exudates  containing  the  streptococci.  Very 
virulent  streptococci  in  small  doses  produce  rapidly  fatal  septicjemia  in 
mice  ;  less  virulent  ones,  a  more  or  less  ])roti'acted  sciUicicmia  or  local 
inflammations  ;  and  the  mou.se  may  die  after  a  longer  or  shorter  period 
from  the  eilcets  of  the  inoculation  without  the  presence  of  stre])tococci 
at  the  autopsy.  Streptococci  are  often  devoid  of  virulence  for  mice. 
The  virulence  for  mice  does  not  correspond  definitely  to  the  character 
and  severity  of  the  streptococcus  infection  in  the  patient  from  whom 
the  streptococci  were  obtained,  although  it  is  a  general  rule,  with  many 
exceptions,  that  the  most  virulent  streptococci  come  from  grave  strepto- 
coccus infections  in  man.  The  pathogenic  properties  of  streptococci  for 
man  have  already  been  mentioned  so  far  as  they  relate  to  surgical  infec- 
tions. (See  pp.  258,  25fl,  292,  and  the  preceding  section,  "  General  Con- 
siderations concerning  Pj-ogenic  Bacteria.") 


BACTERIA   OF  SURGICAL  IXFECTIOXS.  317 

Streptocdcei  dhtaiiied  from  ditferent  sources,  and  even  those  culti- 
vated from  ditferent  cases  of  tiie  siuiie  disease,  vary  greatly  in  morphology, 
cultural  characters,  and  pathogenic  properties.  So  far  as  virulence  is 
concerned,  this  property  alone  cannot  serve  as  a  basis  of  distinction  into 
species,  as  this  is  the  most  variable  of  all  properties  of  pathogenic  micro- 
organisms, and  in  the  case  of  no  micro-organism  more  vurial)le  than 
with  the  streptococcus  jiyogenes.  The  virulence  of  streptococci  a])j)ears 
to  vary  not  only  in  degree,  but  in  kind,  so  that  a  streptococcus  endowed 
with  the  projjerty  of  producing  one  kind  of  infection — as,  for  example, 
er^-sipelas — may  not  be  qualified  under  ordinary  conditions  to  produce 
another  kind  of  infection — as,  for  example,  an  abscess.  But  avc  observe 
such  ready  transformations  in  these  varying  degrees  and  qualities  of 
virulence,  and  such  modifications  of  the  pathogenic  eftects  by  other  cir- 
cumstances than  the  virulence,  such  as  the  manner  and  site  of  invasion 
and  the  susceptibility  of  the  individual,  that  it  seems  hopeless  to  attempt 
any  division  into  physiological  varieties  on  the  basis  of  the  quantity  and 
quality  of  virulence,  significant  as  this  property  is  for  our  understanding 
of  diverse  streptococcus  diseases  in  man. 

jNIany  attempts  have  been  made  to  establish  different  S](ecies  or  vari- 
eties of  streptococci  on  the  basis  of  morphological,  cultural,  and  patho- 
genic differences.  These  attemjits  have  met  with  only  ])artial  success. 
They  have  tended  to  demonstrate  the  great  variability  of  one  and  the 
same  species,  rather  than  to  establish  definite  and  constant  distinctions 
between  supposedly  different  species  or  varieties.  So  far,  at  least,  as  the 
streptococci  which  we  ordinarily  meet,  and  particularly  those  of  interest 
for  human  pathology,  are  concerned,  most  authoritii's  are  of  the  opinion 
that  no  satisfactory  division  into  separate  species  can  at  present  be  estab- 
lished, although  it  is  convenient  to  classify  streptococci  according  to 
certain  jirominent  but  varying  characteristics.  The  characteristics  which 
ai-e  most  useful  in  this  classification  are  those  which  appear  in  bouillon 
cultures.  They  are  the  length  of  the  chains,  the  ]iresence  or  absence  of 
cloudiness  of  the  bouillon,  and  the  kind  of  sediment  jiroduccd  by  the 
growth  of  the  cocci.  We  thus  distinguish  short-chained  streptococci 
{streptococcus  brevis),  long-chained  .streptococci  (streptococcuti  longus), 
streptococci  which  render  Ijouillon  cloudy  and  those  which  do  not, 
streptococci  which  form  Hoeculent  or  sandy  or  scaly  or  viscous  sedi- 
ments. The  uiimc  strcpforoceus  conf/fomcmtiis  is  given  to  a  streptococcus 
which  grows,  without  clouding  the  l)ouillon,  in  the  form  of  dense,  sep- 
arate particles,  scales,  or  thin  membranes  at  the  bottom  and  sides  of  the 
tui)e,  and  on  shaking  the  sediment  it  breaks  up  into  little  specks  without 
producing  unifiirm,  diffuse  cloudiness.  On  microscopical  examination 
the  chains  in  the  latter  case  are  long  and  interwoven  in  conglomerate 
masses.  Streptococcus  chains  may  be  straight  or  wavy  or  twisted. 
These  various  distinctions  are  only  of  relative  value.  One  firm  may 
change  into  another.  Virulent  streptococci  may  be  found  among  all 
the  groujis  mentioned.  The  streptococcus  of  erysipelas  and  most  of 
the  streptococci  from  abscesses  and  sejitica?mia  grow  in  long  chains  in 
bouillon. 

MicrococcKs  Tetragcnus. — Isolated  by  Koch  and  Gaffky  (1S81)  from 
phthisical  cavities.  Grows  in  tetrads  enclosed  in  gelatinous  capsules. 
Stains  by  Gi-am.     Grows  on  all  media  at  room  temperature,  with  or 


318       GENERAL  BACTERIOLOGY  OF  SURGICAL  INFECTIONS. 

without  oxygen.  l<\irnis  clovatcd,  wliitc,  n()ii-li(|iicf'vin(j  colonics  on 
gelatin.  Pathogenic  for  mice,  guinea-pigs,  and,  hy.  intravenous  and 
intra-jjcritoneal  inoculation,  also  I'or  ral)liits.  Found  not  inf're(|Uently  in 
])lithisical  cavities  and  sputum,  oceasiouallv  in  association  with  ])yo- 
genic  cocci  in  abscesses  connected  witli  carious  teeth  and  about  the  neck 
and  jaws  and  middle  ear,  rarely  in  abscesses  elsewhere.  It  has  been 
considered  to  be  non-pathogenic  for  man,  but  it  has  been  found  in  pure 
culture  in  closed  abscesses  in  man,  and  Yiquerat  has  proven  experiment- 
ally that  it  is  capable  of  causing  stipjjuration  in  human  l)eings.  He 
considers  that  suppurations  ])roduced  by  the  tetragenus  alone  are  mild  in 
character,  painless,  with  little  reaction,  easily  cured.  Boutron  jjroposes 
the  name  "  micrococcus  tetragenus  septicus"  for  the  Koch-Gaii'ky  micro- 
coccus to  distinguish  it  from  other  similar  tetragenous  cocci.  The  latter 
are  ncm-pathogcnic. 

Micrococcus  Lanccolattis  (Plate  I.,  Fig.  !j). — Synonyms  :  Diplococ- 
cus  pneumoniffl,  Pnoumococcus  of  Fraenkel  and  AVeichselbaum,  Diplo- 
coccus  lanceolatus.  Micrococcus  of  sputum  septieannia.  Micrococcus  pneu- 
moniiE  cruposfe,  etc.  Discovered  by  Sternberg  in  his  saliva  in  1880. 
Demonstrated  to  be  the  cause  of  lobar  pneumonia  by  Fraenkel  and 
by  Weichselbaum  in  1886.  Capsulatcd,  lance-shaped  coccus,  occurring 
usually  in  ])airs  and  short  chains,  sometimes  in  long  chains.  Stains  by 
Gram.  Grows  best  at  body  tenijierature ;  may  grow  at  tempcratm-e  of 
18—22°  C.  Capable  of  cultivation  on  all  ordinary  alkaline  media,  but 
susceptible  to  slight  variations  in  com]X)sition  of  culture  medium.  Colo- 
nies small,  round,  gray.  Does  not  liquefy  gelatin.  Faculative  anaerobe. 
Loses  virulence  and  dies  quickly  in  cultures.  May  survive  in  dried 
sputum  or  blood  for  four  months.  Killed  in  ten  minutes  at  52°  C. 
A'^irulence  and  other  properties  extremely  variable.  Pathogenic  for 
mice  and  rabbits,  in  less  degree  for  guinea-pigs.  Causes  localized  in- 
flammations and  se])tic8emia. 

Present  often  in  the  mouth  of  healthy  human  beings  (page  258).  Next 
to  the  pyogenic  staphylococci  and  streptococci,  it  is  the  most  common 
cause  of  inflammations  in  human  beings.  It  is  probably  the  sole  specific 
cause  of  genuine  acute  lobar  pneumonia,  and  a  frequent  cause  of  broncho- 
pneumonia, otitis  media,  and  meningitis.  With  or  without  pneumonia 
it  may  cause  inflammation  in  any  organ  or  part  of  the  body.  It  can 
produce  all  kinds  of  inflammatory  exudates — serous,  sero-fibrinous,  puru- 
lent. It  most  frequently  invades  the  body  from  the  bronchi  or  lungs, 
sometimes  from  the  nose,  nasal  sinuses,  and  pharynx,  and  occasionally 
from  the  intestine.  The  list  of  diseases  which  it  is  capable  of  producing 
is  a  very  long  one,  including  inflammations  of  any  of  the  mucous  and 
serous  memlji'anes,  abscesses  in  an}-  part  of  tJie  body,  mono-  and  jioly- 
arthritis,  osteomyelitis,  periostitis,  parotitis,  thyreoiditis,  nephritis,  acute 
ulcerative  endocarditis,  etc.  It  may  cause  septicsemia  with  single  or 
multiple  localizations.  It  is  the  most  frequent  cause  of  metapneumonic 
pleurisies,  including  empya-nia.  Although  it  may  cause  the  gravest  dis- 
eases, it  is  ranked  as  a  relatively  lienign  organism  in  comjtarison  with 
the  streptococcus  pyogenes,  particularly  in  pleurisies  and  suppurations. 
It  may  die  quickly  in  inflammatory  exudates,  as  well  as  in  cultures,  but 
it  may  also  persist  weeks  and  months. 

Micrococcus  Pyogenes  Tenuis. — Found  by  Rosenbach  in  pus  (1884). 


BACTERIA   OF  SURGICAL  INFECTIONS.  319 

Has  been  described  iu  about  twelve  cases  of  suppurative  inflammation. 
It  is  probably  identical  with  the  micrococcus  lanceolatus  (Neumann). 

Micrococcus  Gonorrhoece  or  Gonococcuf!  (Plate  I.,  Fig.  4). — Discovered 
by  Neisser  in  gonorrhcail  pus  in  1879.  First  cultivated  by  Bumm  in 
1885  on  human  blood-serum.  Found  constantly  in  gouorrJKval  pus.  The 
cocci  are  in  jiairs,  with  tiie  adjacent  sides  flattened  against  each  other,  with 
a  clear  interspace  (biscuit  shape).  Grou{)s  of  four  with  adjacent  sides  flat- 
tened also  occur.  Particularly  characteristic  is  the  inclusion  of  the  cocci 
■within  leucocytes,  but  they  occur  also  free  and  attached  to  epithelial  cells. 
Of  diagnostic  importance  ii?  failure  to  stain  by  Gram,  which  distinguishes 
the  gonococcus  from  all  the  preceding  cocci,  but  not  from  the  so-called 
psendo-gouococci  (pp.  2G6  and  207).  Facultative  anaerobe.  Grows  only 
at  body  temperature  or  neighboring  temperature.  Docs  not  grow  on  nu- 
trient gelatin  or  plain  agar,  or  on  the  latter  oidy  with  difficulty  and  occa- 
sionally. Grows  best  on  a  mixture  of  human  blood-serum  and  nutrient 
agar  (one  to  two  or  three  parts)  (Wertheim).  The  addition  of  sterile  human 
urine  improves  the  seruui-agar  mixture  (Steinschneider).  Surface  colonies 
pale,  gravis]),  translucent,  finely  granular,  with  finely  notched  borders. 
Forms  a  membrane  in  bouillon  and  Ijlood-serum  mixed,  leaving  the  fluid 
clear.  Cultures  on  seriun-agar  when  prevented  from  drying  may  live 
forty-five  days.  Inocidation  of  pure  cidtures  into  healthy  human  urethraj 
])roduces  typical  gonorrhcea.  The  gonococcus  is  a  strict  human  parasite. 
It  dies  (piickly  in  dried  pus  outside  of  the  body.  Virulence  soon  disap- 
pears, as  a  ride,  in  artificial  eultiu'cs. 

The  gonococcus  is  in  general  non-pathogenic  for  animals,  but  when 
inoculated  witli  bits  of  agar  into  the  eye  or  into  the  peritoneal  cavity  of 
mice  and  guinca-jjigs  it  may  cause  suppurative  inflannnation.  In  human 
beings  its  growth  is  usually  superficial,  and  by  preference  on  mucous 
membranes  covered  by  cylindrical  or  transitional  epithelium,  but  it  may 
grow  down  deeply  into  connective  tissue  anil  i)etween  muscle-fibres,  and 
may  attack  mucous  membranes  covered  by  Hat  epithelium.  It  is  the 
cause  of  most  cases  of  salpingitis,  pyosalpinx,  and  the  accompanying 
peritonitis.  It  may  produce  genuine  abscesses  (ovarian,  peri-urethral). 
It  may  be  conveyed  by  the  blood-current  and  cause  inflammations  in 
distant  parts,  most  commonly  arthritis,  also  endocarditis,  pericarditis, 
pleiu'isy,  and  myocarditis.  Every  condition  of  rigid  proof  of  the 
causation  of  artiiritis  l)y  the  gonococcus  (exclusive  presence,  isohition  in 
pure  culture,  and  experimental  ])roducti<in  of  gonorrho'a  by  inoculation) 
has  been  fulfilled.  It  is  the  usual  cause  of  gonorrhceal  rheumatism.  All 
of  these  conditions,  complicating  gonorrhcea,  may,  however,  be  produced 
by  other  invading  micro-org-anisms  or  be  mixed  infections  with  the 
gonococcus. 

BarlZ/uf!  Pncii,mo)i!ir  of  Fr'cdJdmJcr  (Pneumo-l)acillus  or  Pneumo- 
coccus  of  Friedliinder). — Isolated  by  Frieilliinder  iu  ISS:')  from  croupous 
])neumonia.  Short,  ]>lump  roils  with  roinided  ends  ])riivided  with  dis- 
tinct capsules  in  the  animal  body.  Does  not  stain  by  Gram.  Facultative 
anaerobe.  Grows  at  room  tem])(!raturc.  Forms  ])rominent,  opacpie-white, 
non-liquefying  colonies  on  gelatin.  Grows  on  all  media.  Ferments  glu- 
cose and  lactose  and  produces  gas-bubbles  on  jiotato.  Pathogenic  for 
mice,  less  s(»  for  guinea-pigs,  and  still  less  sn  for  rabl)its,  which,  however, 
may  become  infected  by  intra-peritoneal  inoculation.    Found  occasionally 


320       GENERAL  BACTERIOLOGY  OF  SURGICAL  INFECTIONS. 

in  tlie  healthy  human  iiKnitli  and  nose,  also  outside  of  the  hody.  It  is 
found  most  frecjuently  in  inilanunations  of  the  mouth,  nose,  and  middle 
car.  It  may  cause  broncho-])ucumonia,  and  has  been  observed  in  a  very 
few  cases  of  empyjema  and  of  meningitis  secondary  to  raiddlc-ear  disease 
and  to  injury.     It  is  a  rare  organism  in  this  country. 

The  badllus  of  rhinoaclerovut  resembles  closely  the  Friedliinder  ba- 
cillus, and,  according  to  some,  there  is  no  reliable  differential  character, 
not  even  the  greater  resistance  to  decolorization  by  Gram's  method,  which 
has  been  the  point  chietly  emphasized.  There  is  a  group  of  capsulated 
bacilli,  resembling  the  Friedlander  bacillus/ some  from  human  beings, 
others  from  animals,  which  have  not  been  satisfactorily  differentiated 
from  each  other  (see  page  '2(J2). 

I>((ci/lus  Pi/oci/anewi  (Phite  I.,  Fig.  2). — First  cultivated  by  Gessard 
from  blue  pus  (1882).  A  slender,  motile,  liquefying  bacillus,  decolorized 
by  Gram,  growing  rapidly,  even  at  ordinary  temperatures,  in  all  cul- 
ture media.  In.  the  jircsence  of  oxygen  forms  bluish,  fluorescent  green 
and  a  whole  scale  of  pigments.  Interesting  modifications  of  character, 
especially  as  to  color  production,  can  be  produced  artificially,  and  are 
observed  under  natural  conditions,  constituting,  according  to  some  writers, 
distinct  varieties  of  the  bacillus.  Is  widely  distributed,  occurring  often 
on  the  human  skin,  in  the  fieces,  and  outside  of  the  body.  In  wounds 
stains  the  dressings  bluish  green,  and  produces  a  somewhat  characteristic 
offensive  odor.  Increases  su])])uration  of  wounds,  usually  with  little 
constitutional  disturbance.  I'atliogenic  for  animals.  Is  found  not 
infrequently  in  perforative  peritonitis  and  ap})endicitis,  sometimes  in 
piilegmons,  otitis  media,  broncho-pneumonia,  and  inflammations  of  serous 
membranes,  associated  usually  with  other  bacteria.  It  was  found  by 
Ernst  in  tuberculous  pericarditis  (Plate  I.,  Fig.  2).  Often  found  in 
diarrhoeal  and  dysenteric  discharges.  May  cause  general  infections  in 
human  beings,  ^yith  or  without  general  infection  it  may  cause  hemor- 
rhagic and  necrotic  enteritis,  a  form  of  ])yocyaneus  infection  in  human 
beings  which  we  have  repeatedly  observed  at  autopsy.  Instances  of 
invasion  of  the  body  from  wounds  by  the  bacillus  pyocyaneus  have  not 
been  observed. 

Bacll/i(f<  Pi/or/enes  Fa'ti(1i(.'<. — First  cultivated  by  Passet  from  stinking 
pus  of  a  perirectal  abscess  (1 885).  Siiort  bacilli  with  rounded  ends.  Cul- 
tures have  a  foul  odor ;  in  other  rcsj)ects  they  do  not  appear  to  differ 
from  those  of  the  bacillus  coli  communis.  This  bacillus  probably  belongs 
to  the  group  of  colon  bacilli.  It  has  been  found  in  pure  culture  in 
closed  abscesses,  but  more  frequently  is  associated  with  other  bacteria. 

Baeillm  Coli  Communis. — Isolated  by  Escherich  from  faces  of  infants 
(1886).  There  isS  a  group  of  bacilli,  called  the  colon  group,  presenting 
similar  characters,  but  with  much  variation  in  their  cultural  and  other 
properties.  Short  rods  with  rounded  ends,  also  longer  forms.  Either 
motile  or  non-motile.  Do  not  stain  by  Gram  in  cultures  or  in  the  tissues, 
but  do  in  normal  stools.  Grow  at  low  as  well  as  high  temperatures  on  all 
media.  Facultative  anaerobes.  Form  large,  spreading,  grayish-white,  non- 
li(iuefying  colonies  with  notched  borders  on  gelatin  and  agar,  sometimes 
circumscribed,  round,  white  colonics.  On  potato,  brownish,  yellowish, 
white,  or  even  scarcely  visible  growtli.  Coagulate  milk,  ferment  glucose, 
lactose,  and  maltose."    Constant  inhabitants  of  the  intestine,  also  widely 


PLATE    1. 


Fig.  1. 


,-\  zy::A'^>^j(- 


Section  through     all    1  abscess  sho       gstapl    1  coccus 
pyogenes  aureus  (p.  315).    Baumgarten. 


''^ 


Cover-glass  i)repuration  of  pericardial 
exudate  showing  bacillus  pyocyaneus 
stained  blue,  and  the  tubercle  bacillus 
stained  red  (p,  320).     Ernst. 


Fig.  3. 


i 


ffM 


-^ 


streptococcus  i>yuj4eiK*s  ;  streptococcus  L'iysii)elatos  fp.  316),    Prudden. 


Fig.  4. 


Fig.  5. 


r  I 


1^ 


Blicrococeiis  gonorrliCEae  or  gonococcus  (p.  319). 
Abbott. 


Micrococcii.s  Lanceoliiiu.s  (p.  :ilS).    Abbott. 


BACTERIA   OF  SURGICAL  INFECTIONS.  321 

distributed  iu  external  nature.  The  colon  bacillus  is  a  frequent  invader 
of  the  internal  organs  in  all  sorts  of  diseases,  especially  when  there  are 
intestinal  lesions.  It  manifests  no  evident  i)atliogenie  action  in  most  of 
these  cases,  and  is  then  \\itliout  clinical  signihcance.  It  occurs  frequently 
associated  with  other  bacteria  iu  infected  wounds  and  other  inflammations 
of  exposed  surfaces.  Here  also  it  does  not  usually  appear  to  cause  seri- 
ous disturbance.  The  fact  that  the  colon  bacillus  is  so  common  and 
widely  distributed,  and  found  so  often  as  a  harmless  invader,  should  lead 
to  mucii  caution  iit  interpreting  the  significance  of  its  presence  when  it 
occurs  in  definite  lesions.  There  is  no  doubt,  hiiwever,  that  it  may  be 
pathogenic  for  man.  It  plays  an  important  role  in  inflammations  of  the 
urinary  tract  and  biliary  passages ;  also,  but  usually  with  less  independence, 
in  peritonitis  and  appendicitis.  The  list  of  diseases  in  wJiich  it  may  be 
found  is  a  very  long  one,  and  includes  inflannuations  in  all  organs  and 
parts  of  the  body.  Attention  has  already  been  called  to  its  })atho- 
genic  properties  for  man  (page  274).  In  general  these  pro])erties  are  of 
a  mild  character.  One  of  its  leading  roles  is  to  invade  territory  already 
occupied  by  other  bacteria  or  previously  damaged.  It  may  be  concerned 
in  the  production  of  gall-stones,  in  the  interior  of  which  it  has  been  found 
by  the  writer  with  great  frequency.  Its  virulence  as  tested  upon  animals 
is  variable,  liut  is  generally  manifest  oidy  after  inoculation  of  large  doses, 
which  kill  by  intoxication  rather  than  infection. 

Bacillus  lactis  ucrogenes  is  described  by  Esch-crich  as  shorter  and 
plumper  than  the  colon  bacillus.  Forms  more  circumscribed,  elevated, 
Mdiite  colonies,  and  coagulates  milk  and  produces  gas  on  ])otato  more 
quickly  and  energetically  than  the  latter.  Predominates  iu  the  upper 
part  of  the  small  intc^stine.  Of  late  most  writers  include  this  bacillus  iu 
the  colon  group,  with  which  it  corresponds  in  its  general  pathogenic 
characters.  It  is  sometimes  described  as  an  opaque  variety  of  the  colon 
bacillus. 

Bacillus  Typhi  Abdominalis. — Mention  is  made  of  this  bacillus,  which 
is  chiefly  of  medical  interest,  not  to  describe  its  characters,  but  to  call 
attention  to  its  capacity  in  rare  instances  to  produce  genuine  sup])urative 
inflammations  in  man,  and  especially  to  cause  periostitis  and  osteomye- 
litis as  a  sequel  of  typhoid  fever.  Most  suppurations  accompanying  or 
following  typhoid  fever  are  due  to  the  pyogenic  cocci  or  are  mixed  infec- 
tions, but  the  tyjihoid  bacillus  may  occur  alone  in  abscesses.  The  most 
connnon  post-typhoid  osseous  affection  is  periostitis  with  cortical  ostitis. 
The  exudate,  when  caused  by  the  typhoid  bacillus  alone,  may  be  dark 
and  thin  with  much  detritus,  or  syrupy  in  consistence,  or  genuine  pus. 
The  affection  is  oftener  in  the  ribs  than  elsewhere,  and  may  be  obstinate 
toward  treatment.  ■  It  may  develop  several  months,  and  it  has  been 
claimed  even  years,  after  tyjihoid  fever.  Some  observations  indicate 
that  the  typhoid  bacillus  may  cause  meningitis  and  inflammations  of 
serous  memi)ranes. 

Bacillus  Proteus. — In  1885,  Hauser  isolated  from  putrefying  sub- 
stances the  rapidly-liquefying  profeus  vulgaris,  the  slowly-liquefying 
proteus  mirabilis,  and  the  non-liquefying  profeus  Zenkeri,  which  he 
originally  supposed  to  be  three  distinct  species,  but  which  he  now 
regards  on  satisfactory  evidence  as  three  varieties  of  the  same  species, 
called  bacillus  jjroteus.      The  main  characters  of  this  bacillus  are  its 

Vol.  1—21 


322       GENERAL  BACTERIOLOGY  OF  SURGICAL  INFECTIONS. 

pleoniorphism,  and  especially  movinjj,  Avanderinii;,  irregular  projections 
and  islands  I'roni  its  colonies  on  gelatin  and  agar  (swarming  colonies). 
It  is  motile.  This  is  one  of  the  most  widely-distributed  bacteria,  and 
is  concerned  in  tiie  decom]iosition  of  animal  and  vegetable  material. 
It  is  not  uncommon  in  the  intestinal  contents.  Althougii  repeatedly 
observed  in  iiiflanuiiations  of  exposed  surfaces,  in  appendicitis,  in  ])er- 
forative  peritonitis,  and  even  in  closed  abscesses  in  association  with  other 
bacteria,  it  has  been  generally  considered  to  be  non-pathogenic  for  man, 
but  our  autopsy  material  has  convinced  us  that  it  may  be  jiathogenic. 
It  may  be  unassociated  with  other  bacteria  in  abscesses  and  in  periton- 
itis, and  it  may  cause  general  infection  l)y  invading  tlie blood  and  inter- 
nal organs  (Flexner).  In  moderate  and  large  doses  it  is  pathogenic  for 
animals. 

BaciUufi  G^dcnudis  Mulii/ni. — Long  spore-forming  l^acillus  resembling 
the  anthrax  bacillus,  but  narrower  and  with  rounded  ends.  Forms  long 
threads.  Strict  anacrol>c.  Ijicpiefies  gelatin  with  gas-production  and 
foul  odor.  Widely  distributed  in  the  soil  and  in  the  fjeces  of  animals. 
Pathogenic  for  animals.  No  instance  is  recorded  of  infection  of  a  pre- 
viously healthy  person  with  this  bacillus,  but  Briegcr  and  Ehrlich  have 
reported  two  cases  of  malignant  oedema  following  the  hypodermic  injec- 
tion of  musk  in  a  typhoid  patient.  The  bacilli  were  accidentally  intro- 
duced l;)y  the  syringe. 

Bacillus  Acrorioics  ('apxiildfiis ;  Bdcilbis  Phlrf/mones  EmpJii/scmafnsce. 
— An  anaerobic  bacillus  first  described  by  A\"elch  and  Nuttall  in  1<S()2  as 
the  cause  of  rapid  formation  of  gas  in  the  blood-vessels  and  organs  after 
death.  Capsulated  thick  bacillus,  averaging  3  to  6  ,«  in  length.  Readily 
stained  by  aniline  dyes,  including  Gram's  stain.  Grows  slowly  at  room 
temperature,  best  at  body  temperatui'c.  Produces  gas  abundantly  in  all 
media  containing  fermentable  substances.  Does  not  form  spores.  When 
injected  subcutaneously  or  intravenously  into  animals  which  are  killed 
shortly  afterward,  it  develops  rapidly,  with  abundant  formation  of  gas 
throughout  the  body.  The  gas  is  odorless  and  burns  with  a  blue  flame. 
There  is  at  first  no  jiutrefactive  decomposition.  In  the  first  case  reported 
by  Welch  and  Nuttall  tiic  autopsy  was  made  eight  hours  after  death 
in  cool  weather,  and  gas  was  abundant  in  the  l)lood-vessels  and  liver. 
This  bacillus  is  doubtless  the  cause  of  the  gas-formation  in  many  cases 
reported  as  death  from  the  entrance  of  air  into  the  veins,  esjjecially  from 
the  uterus  after  abortion,  as  was  proven  to  be  true  in  a  case  reported  by 
Graham,  Steward,  and  Baldwin,  and  in  two  cases  reported  by  P.  Ernst. 
This  bacillus  was  found  in  a  case  of  emphysematous  gangrene  of  the 
hand  reported  by  Mann.  It  is  probably  identical  with  the  bacillus  found 
by  E.  Fraenkel  in  four  cases  of  emiiliysematous  phlegmon  reported  in 
1893,  and  called  by  him  bacillus  phlcymoncs  emphysematoscc.  It  has 
been  found  by  the  writer  in  three  cases  of  perforative  peritonitis.  It 
may  cause  emphysema  of  the  subperitoneal  tissues.  It  is  probably  a 
rather  widely  distributed  bacillus. 

Bacillus  i);>/i//ien"rt'.— Observed  by  Klebs  (1883),  first  cultivated  and 
accurately  descrilied  by  Loffler  (1884).  Straight  or  slightly  curved 
rods,  averaging  1.2  to  2.6  /i  in  length,  characterized  especially  by  irreg- 
ularities in  shape  and  staining.  Particularly  characteristic  are  swollen 
ends  and  deeply-staining  chromatin-granules  in  the  bacilli.     Stains  by 


BACTERIA   OF  SURGICAL  INFECTIONS.  323 

Gram.  Not  motile.  Does  not  form  spores.  Facultative  anaerobe. 
Optimum  temperature  for  growth  33-37°  C.  Grows  only  slowly  and 
slitriitly,  if  at  all,  below  20°  C.  Grows  on  all  alkaline  culture  media, 
invisibly  on  potato,  best  on  Loffler's  blood-serum  bouillon  mixture.  Does 
not  liquefy  gelatin.  Forms  on  agar  grayish-white,  granular  colonies 
with  slightly  irregular  margins.  In  bouillon  grows  in  the  form  of 
small  grayish  particles,  with  or  without  clouding  of  the  medium,  often 
with  formation  of  surface  membrane.  Particularly  important  as  a 
diagnostic  critei'ion  is  the  change  of  the  alkaline  to  acid  reaction  by 
forty-eight  hours'  growth  in  bouillon  containing  carbohydrate.  Thermal 
death-point,  58°  C  in  ten  minutes.  May  survive  in  some  culture  media 
eighteen  months,  but  may  die  in  three  or  four  weeks.  Lives  longer  in 
the  dark  than  when  exposed  to  light.  Resistant  to  desiccation.  jMay 
survive  for  three  to  five  months  in  dry  membranes,  but  usually  dies 
sooner.  Cultures  dried  on  threads  survive  three  to  four  weeks  at  room 
temperature.  Both  virulent  and  non-virulent  diphtheria  bacilli  occur, 
the  latter  rarely  in  diphtheria.  Pathogenic  for  many  animals,  and 
especially  for  guinea-pigs.  By  suhcutaneous  inoculation  there  is  pro- 
duced extensive  local  inflammation  antl  necrosis.  The  animal  dies 
usually  in  thirty-six  to  sixty  hours,  with  necrotic  foci  in  various  internal 
organs  and  serous  transudates  in  the  serous  cavities.  The  bacilli  are 
found  only  near  the  seat  of  inoculation  or  in  very  small  number  in  the 
organs.  With  less  virulent  cultures  or  smaller  doses  subacute  and 
chronic  infections  or  intoxications  ensue.  Genuine  pseudo-membranes, 
as  a  rule  with  little  tendency  to  sjiread,  follow  inoculation  of  nuicous 
membranes  superticially  injured.  The  virulent  diphtheria  bacillus  pro- 
duces by  its  growth  in  cultures  or  in  the  animal  body  a  powerful  poison, 
called  the  toxin  or  toxalbnmin  of  diphtheria,  to  which  the  constitutional 
symptoms,  the  lesions  of  internal  organs,  and  the  paralysis  are  due. 

The  diphtheria  bacillus  is  the  cause  of  all  cases  of  genuine  diphtheria. 
Similar  pseudo-mcml)ranous  inflammations  of  the  throat  and  air-passages 
may  be  caused  by  streptococci.  The  intensity  of  the  affection  caused 
by  the  dij)htlieria  bacillus  varies  from  a  slight  inflannnation  without 
false  membrane  to  the  gravest  pseudo-membranous  inflanmiatious. 

The  dipiitheria  bacillus  is  incapable  of  attacking  the  intact  skin.  It 
may,  however,  produce  pseudo-membranous  inflannnations  on  excoriated, 
ulcerated,  and  wounded  skin.  Neisser  has  reported  the  case  of  a  child 
five  and  a  half  years  old  with  diphtheria  of  the  throat  in  whom  thick, 
firmly-adherent  pseudo-membrane  covered  the  skin  alwut  the  anus  over 
a  sjiace  10  cm.  long  and  4  cm.  broad.  There  was  cedema  of  the  scrotum 
and  |)enis.  L<)tfler  bacilli  were  found  in  the  false  membrane  and  through- 
out the  infiltrated  corium.  The  localization  of  the  diphtheria  bacillus 
in  cutaneous  surfaces  which  have  been  deprived  of  the  epithelial  cover- 
ing by  excoriation,  eczema,  ulceration,  herjics,  wounds,  has  been  observed 
many  times  in  persons  afl'ected  witli  diphtheria  of  the  throat,  although 
it  is  not  common.  This  localization  may  be  attended  by  a  pseudo- 
membrane,  or  by  simple  superficial  necrosis,  or  by  ordinary  suppuration 
or  inflannnation  in  no  way  suggesting  diphtheritis.  Park  found  diph- 
theria bacilli  in  two  cases  in  wounds  of  the  finger  received  by  physicians 
in  intubating  children  with  di[)htlieria.  They  persisted  for  six  weeks 
in  one  case.     Wright  has  demonstrated  the  presence  of  this  bacillus  in 


324       GENERAL  BACTERIOLOGY  OF  SURGICAL  INFECTIONS. 

excoriated  or  ulcerated  surfaces  of  the  skin  in  7  cases,  in  paronychia  in 
1,  in  mastoid  abscess  in  1,  in  ])urulc'nt  ct)niunctivitis  in  1, — all  in  cases 
of  diphtheria.  The  dipjithcritic  })rooess  may  extend  by  continuity  to 
a  tracheotomy  wound.  More  freipiently  the  wciund  is  unatfected,  even 
in  cases  where  the  diphtheria  bacillus  may  be  demonstrated  upon  its 
surface.  Extensive  necrotic  and  septic  involvement  of  tracheotomy 
wounds  is  more  frequently  due  to  streptococci,  with  or  without  associ- 
ation with  the  diphtheria  bacillus,  than  to  the  latter  micro-organism 
alone.  Brunner  has  reported  three  cases  of  infection  of  wounds  with 
the  diphtheria  bacillus  in  association  with  pyogenic  cocci  in  persons 
without  demonstrable  connection  with  other  cases  of  diphtheria  and 
Avithout  any  affection  of  the  throat.  In  only  one  case  was  there  pseudo- 
membrane.  The  presence  of  the  diphtheria  bacillus  was  not  suspected 
in  any  of  these  cases  before  the  bacteriological  examination. 

In  this  connection  a  few  words  may  be  said  regarding  the  general 
subject  of  wound  diphtheritis,  concerning  which  nuich  confusion  exists. 
Here,  as  well  as  in  diphtheritis  of  mucous  membrane,  it  is  important 
to  bear  in  mind  that  the  term  "  diphtheritis  "  is  a  purely  anatomical  one, 
and  implies  nothing  as  to  the  causation  of  the  affection.  The  term 
"  diphtheria,"  on  the  other  hand,  should  be  restricted  to  the  affection 
caused  by  the  Loftier  l)acillus  wherever  this  may  be  localizi'd.  There 
are  three  anatomical"  conditions  of  a  Mound  to  which  the  epithet  "  diph- 
tlieritic  "  has  been  applied — namely,  first,  the  presence  of  an  adherent 
fibrinous  false  membrane  incorjiorated  with  underlying  necrosis  of  the 
tissues ;  second,  the  presence  of  a  fibrinous  pseudo-membrane  loosely 
attached  to  the  underlying  tissues,  which  may  present  no  distinctive 
alteration  ;  and,  third,  more  or  less  extensive  necrosis  of  the  tissues  of 
the  wound  without  a  distinct  false  membrane.  Only  the  first  condition 
is  properly  called  diphtheritis  ;  the  second  may  be  called  simple  pseudo- 
membranous or  croupous  inflammation,  and  the  third  is  necrotic  inflam- 
mation. 

Wound  diphtheria  is  infection  of  a  M'ound  by  the  Loffler  bacillus. 
It  may  or  may  not  be  wound  diphtheritis  in  the  anatomical  sense. 
Wound  diphtheria  may  manifest  itself  as  a  simple  inflammation,  or 
inflammation  with  sujjerficial  necrosis,  or  inflammation  with  more  or 
less  adlierent  pseudo-membrane.  Pyogenic  cocci  are  usually  associated 
with  the  L(')ffler  bacillus  in  the  diplitheria  of  wounds.  Paralysis  may 
follow  wound  di])htheria.  As  the  same  anatomical  conditions  in  a  wound 
may  be  produced  by  various  causes,  a  positive  diagnosis  of  wound  diph- 
theria can  be  made  only  by  bacteriological  examination.  The  conditions 
as  regards  var'ying  intensity  and  character  of  the  infection,  association 
with  other  bacteria,  particularly  streptococci,  and  the  necessity  of  a  bac- 
teriological examination  to  establish  the  diagnosis,  are  in  no  way  differ- 
ent in  the  diphtheria  of  wounds  from  those  in  diphtlieria  of  mucous 
membranes.  As  has  already  been  stated,  wound  dijihtheria  may  occur 
without  demonstrable  connection  with  cases  of  dijihtheria  and  without 
affection  of  the  throat  in  the  individual  attacked,  but  such  occurrences 
are  rare. 

Diphtheritic,  necrotic,  and  croupous  inflammations  of  wounds  are 
caused  most  frequently  by  other  micro-organisms  than  the  Lofiler 
bacillus.     Here,  as  with  similar  inflanuuations  of  mucous  membranes, 


BACTERIA    OF  SURGICAL  INFECTIONS.  325 

the  streptococcus  pyogenes  appears  to  be  an  important  causative  agent, 
so  far  as  can  be  judged  from  the  small  number  of  cases  hitherto  exam- 
ined bactcriologically.  In  this  comparatively  rare  class  of  streptococcus 
infection  of  wounds  the  intensity  and  extent  of  the  inflammation  vary 
witiiin  wide  limits. 

It  is  not,  or  formerly  was  not,  a  particularly  rare  occurrence  for 
coherent  false  membranes  to  develop  upon  granulating  surfaces  without 
notable  disturbance  in  the  process  of  repair  and  Mdthout  constitutional 
disturbance.  The  membrane  in  these  cases  can  be  readily  stripped  off, 
after  which  another  membrane  is  likely  to  form.  It  has  been  proposed 
to  call  tiiis  relatively  inoffensive  wound  complication  "  wound  croup,"  in 
distinction  from  the  more  severe  Avound  diphtheritis.  In  two  cases  of 
croupous  membranes  on  granulations  Brunner  found  the  streptococcus 
pyogenes  in  pure  culture.  In  similar  cases  he  and  Tavel  have  found 
also  the  bacillus  coli  communis  in  pure  culture.  The  condition  may 
doubtless  be  associated  with  the  presence  of  various  micro-organisms, 
and  is  not,  therefore,  a  specific  one.  In  croupous  inflammations  of 
fresh  wounds  Brunner  found  the  streptococcus  pyogenes  in  association 
with  other  pyogenic  cocci. 

How  much  the  development  of  diphtheritic  and  necrotic  inflamma- 
tions of  wounds  is  influenced  by  the  general  condition  of  tlie  patient 
is  shown  by  the  greater  frccjuency  of  its  occurnMice  in  persons  pros- 
trated with  typhoid  fever,  scarlet  fever,  septicaemia,  pytemia,  and  other 
debilitating  causes. 

Diphtiieritic  inflammation  of  operative  woimds  involving  the  mouth 
and  the  bladder  is  more  common  than  a  similar  affection  of  wounds  in 
other  parts  of  the  body.  The  Loffler  bacillus  is  not  concerned,  as  a 
rule,  with  diphtheritis  of  these  wounds,  any  more  than  it  is  with  diph- 
theritic cystitis  or  enteritis. 

Much  interest  attaches  to  the  question  of  the  causation  of  hospital 
gangrene,  that  frightful  sc(.)urge  of  pre-antiscptic  surgery  iu  crowded 
hospitals,  particularly  in  military  hosjiitals.  Hospital  gangrene  has 
been  designated  "  wound  diphtheritis,"  but  it  differs  from  the  necrotic 
and  diplitheritie  inflanunatidus  of  wounds,  which  are  now  occasionally 
observed,  in  many  features,  particularly  by  its  phagedenic  eliaracter  and 
its  mortality.  It  has  apparently  disappeared,  at  least  from  civilized 
coiuitries,  and  there  has  been,  therefore,  no  opportunity  to  make  a  bac- 
teriological examination  by  modern  methods  of  any  case  of  this  disease. 
Although  some  of  the  older  writers  identified  the  cause  of  hos})ital  gan- 
grene witli  that  of  true  diphtlieria,  it  seems,  with  our  present  Ivuowledge, 
highly  im]irobal)le  _that  tliis  is  true.  Our  ol)servations  of  the  effects 
produced  by  the  diphtheria  bacillus  with  or  without  association  with 
other  Ijacteria  in  wounds  do  not  indicate  that  this  orgtmism  can  have 
played  any  essential  role  in  the  causation  of  hospital  gangrene.  Some 
authorities  are  of  the  opinion  that  hospital  gangrene  is  a  s])ceific  infec- 
tion tine  to  a  specific  micro-organism  wliich  has  disappeared  from  civil- 
ized countries,  as  the  micro-organism  of  tlic  plague  has  disappeared.  It 
seems  to  the  writer  more  probable  that  it  was  due  to  pyogenic  liacteria 
which  still  exist,  l)ut  whicli  under  the  special  conditions  prevailing 
where  hospital  gangrene  occurrcid  had  acquired  a  degree  and  kind  of 
virulence  with  which  we  are  no  longer  familiar.     Thanks  to  antiseptic 


326        (IKNERAL  BACTERIOLOGY  OF  SURGICAL  INFECTIONS. 

surgery,  these  special  coiulitions  aiv  not  likely  to  be  repeated  in  civilized 
countries. 

BucaUus  Tctuiii. — Observed  by  Nieolaier  (1884)  in  wounds  in  cases 
of  tetanus  and  demonstrated  in  garden  eai'th,  first  obtained  in  pure 
culture  by  Kitasato  (1889).  Slender,  straight  bacilli,  varying  in  length 
from  sliort  rods  to  long  threads.  iSluggishly  motile.  Splierical  spores, 
tliirker  than  the  rods,  develop  at  one  end  of  the  bacilli,  giving  them  a 
drumstick  or  pin  shape,  ytains  by  Gram.  Anaerobic.  Grows  best  at 
body  temperature,  slowly  at  18-20°  C,  not  at  all  below  14°  C.  Spores 
are  formed  in  cultui'cs  at  body  temperature  in  thirty  hours,  in  cultures 
at  20°  to  25°  C,  not  until  after  a  week.  Grows  in  nutrient  gelatin, 
whicli  is  slowly  liquefied  with  slight  gas  production  ;  in  agar  and  bouillon 
wJien  free  oxygen  is  excluded.  Growth  in  gelatin  is  fuzzy,  radiating, 
like  a  thistle.  Dried  spores  live  months  and  years.  Cultures  contain- 
ing spores  dried  on  silk  threads  were  found  alive  after  several  months 
by  Kitasato.  Henrijean  demonstrated  living,  virulent  tetanus  spores  on 
a  j)iece  of  wood  which  had  been  extracted  eleven  years  previously  from 
the  wound  in  a  boy  with  fatal  tetanus.  The  sjiores  are  killed  in  five 
minutes  by  moist  heat  at  100°  C.  They  withstand  in  the  moist  con- 
dition for  an  hour  a  tem])erature  of  80°  G. — a  jtrojierty  ^\•hich  \vas 
utilized  by  Kitasato  to  destroy  other  bacteria  in  obtaining  pure  cultures 
of  the  tetanus  bacillus.  The  spores  survive  and  jireserve  their  virulence 
for  ten  hours  in  5  per  cent,  carbolic  acid  ;  they  are  killed  in  fifteen  hours. 
They  are  not  killed  by  putrefactive  Ijacteria. 

The  tetanus  bacillus  is  more  or  less  pathogenic  for  nearly  all  warm- 
blooded and  some  col(l-l)looded  animals.  Infection  takes  place  only 
through  a  wound.  The  period  of  incubation  varies  from  a  few  hours  to 
several  days,  according  to  the  susceptibility  of  the  animal  and  the  dose. 
Experimental  tetanus  corresponds  in  all  essential  particulars  to  human 
tetanus.  Tetanic  s})asm  appears  first  in  the  muscles  nearest  the  seat  of 
inoculation. 

Tetanus  is  a  toxic  infection.  The  bacilli  multiply  only  in  the  imme- 
diate neighborhood  of  the  wound,  and  do  not  invade  the  blood  and 
organs.  Inoculation  with  jiure  cultures  is  a  pure  intoxication  as  a  rule, 
with  but  little  nuiltiplication  of  the  bacilli,  so  that  at  the  autopsy  it  may 
be  difficult  to  find  any  bacilli.  ^\nien  imjnire  cultures  and  foreign 
bodies  are  introduced  into  the  wound  the  bacilli  are  more  readily 
demonstrable  at  autopsy.  There  are  no  demonstrable  lesions  of  internal 
organs  in  experimental  tetanus. 

All  of  the  symptoms  of  tetanus  can  be  produced  by  the  germ-free 
filtrate  of  tetanus  cultures.  It  is  the  only  infectious  disease  known  every 
feature  of  which  can  be  produced  experimentally  by  injection  of  the  poi- 
son without  the  micro-organisms.  In  the  case  of  diphtheria  all  of  the 
symptoms  and  lesions  can  be  produced  by  the  jjoison  except  the  local 
false  memlirane.     This  requires  the  presence  of  the  liacilli. 

Brieger  found  in  impure  tetanus  cultures  foiu'  crystallizable  alkaloidal 
substances  belonging  to  the  class  of  ptomaines.  Three  of  these  he  called 
tetanin,  tetanotoxin,  and  spasmotoxin.  He  found  also  an  unnamed  base. 
As  these  ptomaines  produced  spasms  by  injection  into  animals,  this  residt 
was  at  first  thought  to  indicate  that  the  poison  of  tetanus  had  been  iso- 
lated in  a    state  of  chemical  purity.      Subsequent  investigations   have 


BACTERIA    OF  SURGICAL  INFECTIONS.  327 

shown  that  these  jitoinai'ne.s  do  not  rci)ro(Uice  all  of  tlic  characteristic 
symptoms  of  tetanus.  They  are  not  the  real  tetanus  poison,  and  no 
particular   interest  any  longer  attaches  to  them. 

The  real  poison  of  tetanus  belongs  to  a  different  class  of  substances — 
namely,  the  so-called  toxic  proteids  or  toxalbumins,  substances  al)out 
■which  we  know  yery  little  chemically,  but  a  great  deal  physiologically. 
We  do  not  eyen  know  j)ositiyely  tiiat  the  tetanus  toxin  is  a  proteid,  but 
it  is  generally  assumed  to  be.  To  this  same  class  of  substances  belong 
the  toxin  of  diphtheria,  the  venom  of  snakes,  and  certain  poisonous  sub- 
stances produced  l)y  vegetable  cells,  as  ricin,  abrin,  robin. 

The  specific  tetanus  toxin  has  been  demonstrated  both  in  cultures  of 
the  tetanus  bacillus  and  in  the  bodies  of  animals.  It  has  been  found 
in  the  blood  both  during  life  and  after  death.  It  does  not  appear 
to  be  eliminated  iu  ap[)reciable  amount  by  the  urine  unless  very  large 
doses  are  given.  According  to  Kitasato,  the  poison  is  destroyed  in  the 
presence  of  water  in  five  minutes  at  65°  C,  in  one  and  a  half  hours  at 
55°  C ;  it  stands  drying  at  ordinary  temperatures  ;  is  not  injured  by 
dilution  with  water  or  bouillon  ;  is  sensitive  to  acids  and  alkalies.  It  is 
destroyed  by  the  acid  gastric  juice.  It  is  injured  by  exposure  to  light. 
So  sensitiye  is  the  tetanus  poison  to  chemical  reagents  that  Kitasato  was 
unable  to  find  any  means  of  obtaining  the  poison  in  a  condition  approach- 
ing purity,  and  he  expressed  ignorance  as  to  its  real  nature.  Brieger  and 
Cohn  have,  however,  been  more  successful,  and  have  isolated  a  substance 
possessing  the  properties  of  the  tetanus  poison  in  a  condition  approac^hing 
purity.  As  this  sul>stance  was  found  to  be  without  most  of-  the  proteid 
reactions,  they  consider  that  it  is  not  an  albumin  in  the  ordinary  sense 
of  that  term. 

The  tetanus  toxin  is  of  appalling  potency.  Kitasato  obtained  liquid 
cultures  of  such  virulence  that  0.00001  ccm.  of  the  germ-free  filtrate, 
corresponding  to  0.00023  mgm.  of  the  dried  filtrate,  sufficed  to  kill  a 
mouse  with  tetanus.  ( )f  course  only  a  i)art  of  the  dried  substance  is  the 
real  jxiison.  Of  tlie  jiuritied  substance  obtained  by  Brieger  and  Cohn, 
who  had  at  their  tlisposal  cultures  of  less  primary  virulence  than  those 
of  Kitasato,  0.000,000,05  grm.  killed  a  mouse  of  15  grm.  weight.  As 
the  fatal  dose  of  the  tetanus  poison  increases  with  much  regularity  in  pro- 
portion to  the  weight  of  the  animal,  this  would  represent  0.23  mgm.  as 
the  fatal  dose  for  a  man  weighing  70  kilo.  When  it  is  coiisidered  that 
the  minimal  fatal  dose  of  atropine  for  an  adult  is  l.'>0  mgm.  and  of 
strychnine  is  30-100  mgm.,  some  conception  of  the  terrible  energy  of 
this  bacterial  weapon  can  be  obtained.  The  substance  se])arated  by 
Brieger  and  Cohn  was  not  in  a  state  of  chemical  j^urity.  The  tetanus 
poison,  like  the  diphtheria  poison,  does  not  cause  symptoms  immediately 
after  its  introduction.  With  small  doses  it  may  he  days  before  recog- 
nizable sym]>toms  ap|)ear.  This  behavior  is  unlike  that  which  we  are 
accustomed  to  attril)ute  to  ciiemical  poisons,  and  raises  the  question 
whether  the  poison  may  not  be  reproduced  in  the  body,  or  whether  the 
substance  injected  is  itself  the  poison,  and  may  not  be  in  the  nature  of 
an  enzyme  which  leads  to  the  production  of  the  real  poison  within  the 
body.     These  (juestious  cannot  at  present  be  answered. 

An  interesting  examjile  of  the  effect  of  the  pure  tetanus  toxin  upon 
man  is  reported   by  Xicolar.     In  working  with  the  filtrate  of  a  tetanus 


328       GENERAL  BACTERIOLOGY  OF  SURGICAL  INFECTIONS. 

culture  he  accidentally  stuck  the  point  of  the  needle  of  a  hypodermic 
syringe  containint;-  some  of  the  fluid  into  iiis  left  hand.  Only  the  moist- 
ure adiiering  to  the  needle  was  introduced  into  tiie  puncture.  After 
three  and  a  half  days  the  iirst  symptoms  of  tetanus  were  manifested  by 
contracture  of  the  left  thumb.  There  followed  in  succession  contraction 
of  the  hand,  the  arm,  then  trismus,  opisthotonos,  general  contractures, 
and  convulsions.  The  treatment  was  by  large  doses  of  chloral.  After 
three  weeks  improvement  began,  and  recovery  was  comi)letc  after  forty- 
one  days.  In  this  uui(jue  case  the  tetanus  toxin  was  introduced  in  min- 
imal amount  without  the  bacilli.  Nicolar,  in  view  of  the  fact  that  no 
symptoms  were  manifested  until  the  third  day,  adopts  the  view  that  the 
culture  fluid  does  not  contain  the  real  poison,  but  produces  it  by  a  kind 
of  fermentation  after  introduction  into  the  body. 

The  distribution  of  the  tetanus  liacillus  and  the  factors  favoring  infec- 
tion with  tetanus  have  already  been  described  (pj).  25.'j,  2(J5,  270,  and  28!:l). 

Susceptible  animals  may  be  rendered  immune  from  tetanus  by  the 
injection  of  the  tetanus  poison,  at  first  weakened  by  chemical  agents  or 
heat,  and  then  administered  in  full  strength  in  constantly  increasing 
doses.  This  is  antitoxic  inuniuiitv,  already  dcscrilicd,  which  has  nothin<>: 
to  do  with  natural  imnuuiity.  The  hen  is  natui'ally  immune  from  tetanus, 
but  not  by  virtue  of  any  antitoxic  power  of  the  blood.  The  blood-serum 
and  other  fluids  of  animals  rendered  artificially  imnuuie  from  tetanus  are 
capable,  by  virtue  of  their  antitoxin,  of  rendering  susceptible  animals 
resistant  to  tetanus  (passive  immunity),  or  even  of  preventing  the  develop- 
ment of  the  disease  or  of  curing  the  disease  after  reception  of  the  virus. 
Bchring  in  1.S92  reported  that  in  the  course  of  two  years  he  had  by  suc- 
cessive injection  of  increasing  doses  of  the  tetanus  toxin  rendered  a  horse 
so  highly  immune  that  the  immunizing  value  of  its  blood-serum  was 
1  to  10,000,000,  by  which  is  meant  that  TTiWoTrTTotli  fcm.  of  serum  will 
protect  1  grm.  weight  of  mouse  from  the  effects  of  the  subsequent  injection 
of  the  smallest  fatal  dose  of  the  tetanus  poison,  or  1  ccm.  of  serum  suffices  to 
imnuuiize  5()0,(l()0  mice,  weighing  each  20  grams,  or  200  shee]>,  weighing 
each  50  kilo.  When,  however,  the  attempt  is  made  to  prevent  the  develop- 
ment of  the  disease  immediately  after  the  reception  of  the  virus,  a  larger 
quantity  of  the  serum  is  required  to  afford  protection  than  a  few  hours 
previously,  and  as  time  elapses  the  amount  of  scrum  required  rajiidlv 
increases,  until,  as  soon  as  the  very  first  symptoms  of  the  minimal  fatal 
dose  of  tetanus  poison  appear  in  the  mouse,  one  thousand  times  the 
quantity  of  serum  necessary  for  simple  preventive  imnumization  must 
be  injected.  After  twenty-four  hours  the  necessary  quantity  of  serum 
possessing  an  immunizing  value  of  1  to  1,000,000  is  too  great  to  be  intro- 
duced into  the  animal.  To  produce  the  same  curative  effects  in  large 
animals  as  in  small  it  is  necessary  to  inject  jiroportionately  larger  amounts, 
the  dose  being  in  approximately  direct  ratio  to  the  respective  weights  of 
the  animals.  These  considerations  manifestly  suggest  serious  difficulties 
in  the  application  of  the  antitoxic  treatment  of  tetanus  to  human  beings. 
But  there  is  another  difficulty  of  probably  greater  force — namely,  that 
we  have  no  indication  that  tetanus  will  result  from  a  woimd  in  man 
until  characteristic  symptoms  have  appeared.  By  that  time  tetanus 
poison  has  accumulated  in  considerable  amount  in  the  system.  Kitasato 
was  unable  to  prevent  the  develojjment  of  tetanus  in  mice  by  the  com- 


PLATE    I  I. 


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II 


I      -}l 


V 


Tubercle  bacillus  and  streptcicocci  in  s])Utum 
(p.  329).    Abbott. 


Anthrax  bacillus  in  section  of  liver  of  mouse 
(p.  331).    Abbott. 


1      f 


Tetanus  bacillus  ip.  326).    Abbott. 


Fig.  6. 


Fig.  4. 


Section  of  glanders  nodule,  sbowing  glanders  bacilli 

(p.  330).     FLt'GGE. 


'<.••,'■"»■•'' 


.. '  c  ■  ^  ^  , ?,  V-"-  ■  '-V-  «■■  -.?  vs.g 


Longitudinal  section  of  rabbit's  tibia  showing  osteomyelitis  produced  by  intra- 
venous injection  of  the  staphylococcus  pyogenes  aureus.  The  cocci  are  colored 
blue,  a,  Compact  tissue  of  bone;  6,  Haversian  canal  filled  with  staphylococci 
(p.  31.i).    L.4NNELONGi'E  and  Achard. 


BACTERIA    OF  SURGICAL  IXFECTIOXS.  329 

pletc  excision  and  thorough  cauterization  of  tiie  wound  one  hour  after 
inoculation  with  tetanus  bacilli.  It  is  not  positively  proven  that  cura- 
tive antitoxic  serum  neutralizes  poison  which  has  already  been  received 
into  the  system  before  injection  of  the  serum,  although  it  is  capable  of 
neutralizing  poison  formed  after  its  administration.  \Ve  stand  in  a  much 
less  favoral)le  position  for  tiie  successful  treatment  of  human  tetanus  by 
antitoxin  than  is  tiie  case  with  diphtheria,  where  the  conditions  are  more 
favorable  both  as  regards  progressive  increase  of  dosage  in  proportion  to 
the  weight,  and  especially  as  regards  the  possibility  of  beginning  treat- 
ment before  the  absorption  of  large  quantities  of  the  poison.  These  are 
the  scientific  considerations  relating  to  the  treatment  of  tetanus  by  anti- 
toxin. Its  practical  a]>plication  and  the  results  of  treatment  in  human 
beings  belong  to  the  article  on  Tetanus  in  this  work. 

Baci/las  TiihciTulosis. — Discovered  and  first  cultivated  liy  Koch  (1882), 
independently  and  at  about  the  same  time  demonstrated  microscopically 
in  tubercles  by  Baumgarten.  Slender,  straight,  or  slightly  curved  or  bent, 
non-motile  rods,  1.5  to  4  //  in  length,  which  averages  live  to  six  times 
the  breadth.  In  unstained  specimens  glistening  dots,  in  stained  speci- 
mens clear  spots,  are  often  seen  in  the  rods,  which  thereby  j)resent  a 
beaded  appearance.  Tiiese  are  interpreted  by  Kc)ch  and  others  as  spores, 
but  this  has  not  been  proven.  Xo  greater  resistance  to  heat  and  other 
injurious  agencies  has  been  demonstrated  for  bacilli  containing  these  sus- 
pected spores  than  for  l)acilli  without  them.  Tubercle  bacilli  take  up 
staining  dyes  with  difficulty,  Imt  when  once  thoroughly  stained  by 
intense  aniline  dyes  they  retain  the  color  after  it  has  been  extracted  by 
acids,  alcohol,  and  other  dec<ilorizers  from  all  other  known  bacteria 
except  the  leprosy  bacillus  and  some  examples  of  smegma  bacilli.  (See 
p.  254.)  It  is  by  this  peculiar  staining  reaction  that  tubercle  bacilli 
are  differentiated  from  other  bacteria.  The  tubercle  bacillus  grows  best 
in  the  presence  of  free  <ixygen,  but  is  capalile  of  growth  without  free 
oxygen.  0])timtnn  temperature  for  growth,  37  to  39°  C.  Does  not 
grow  below  29°  C.  Was  first  cultivated  by  Koch  on  solidified  cow's 
blood-serum ;  has  since  been  culti\'ated  on  potato,  and  on  nutrient  agar 
and  bouillon  to  Avhich  5  to  6  per  cent,  glycerin  has  been  added.  On 
blood-serum  the  growth  first  becomes  visible  after  ten  to  fourteen  days. 
It  forms  dry,  lustreless,  compact  white  scales,  loosely  attached  to  the  sur- 
face. By  coalescence  of  the  (Milonies  extensive  membranous  growtiis  are 
formed.  GroMs  in  the  form  of  a  membrane  on  the  surface  of  fluid  media, 
without  clouding  the  fluid.  The  tubercle  bacillus  is  the  most  resistant 
to  heat  of  all  pathogenic  bacteria  not  positively  proven  to  form  spores. 
The  stiitements  of  different  experimenters  as  to  its  thermal  death-point 
arc  so  widely  divergent  that  bacilli  from  different  sources,  or  at  least 
under  different  conditions,  would  seem  to  vary  in  this  respect;  but  it  is 
more  prol)able  tiiat  tlie  discordant  results  are  due  to  failure  to  ensure 
exposure  of  tiie  bacilli  to  the  actual  temperature  of  the  surrounding 
fluid.  The  physical  conditions  as  regards  distribution  of  the  temper- 
ature in  heatecl  animal  fluids,  culture  media,  etc.,  especially  when  solid 
masses  are  present,  are  not  of  so  simple  a  nature  as  many  of  the  experi- 
menters upon  the  subject  of  the  thermal  death-point  of  bacteria  seem  to 
suppose.  According  to  tlic  careful  ex]ieriments  of  Foi-ster,  tnljcrcle 
bacilli  are  killed,  or  at  least  arcv  rendered  incapable  of  infecting  guinea- 


330       GENERAL  BACTERIOlJXiY  OF  SUBOICAL  INFECTIONS. 

pigs,  V)y  ten  niiiiiitcs'  exposure  to  a  teni])oratiiro  (if  70°  C  and  l)y  one 
liour's  t'Xjiosure  to  60°  C.  Tlioy  were  not  killed  in  forty-five  minutes 
by  heatinjr  to  60°  C.  They  are  surely  killed  in  a  few  minutes  by  the 
boiling  temperature.  They  ro'tain  their  vitality  in  dried  sputum  for  nine 
or  ten  months,  but  at  the  last  with  some  loss  of  virulence.  They  resist 
putrefaction  for  a  considerable  time.  They  are  killed  in  sj)utum  by  3 
per  cent,  carbolic  acid  in  twenty  hours ;  they  are  killed  in  a  few  minutes 
by  3  to  5  per  cent.  carl)olic  acid  when  the  acid  can  come  into  direct 
contact  with  the  bacilli.  They  resist  the  action  of  the  gastric  juice. 
AA'hen  expo.sed  in  thin  layer  to  the  direct  action  of  the  sun's  rays  they 
are  killed  in  a  few  minutes — much  more  slowly  when  in  a  thick  layer. 

The  tubercle  bacillus  is  a  strict  parasite,  incapable  under  ordinary 
conditions  of  multiplication  in  the  outer  world,  but  capable  of  jirolonged 
survival  outside  of  the  l)ody.  It  is  the  sole  cause  of  tuberculosis.  The 
pathogenic  manifestations  of  the  tubercle  bacillus  have  been  described 
by  Dr.  Councilman  (p.  2.">9),  and  will  be  further  considered  in  the  articles 
treating  of  the  various  forms  of  surgical  tuberculosis. 

The  bacillus  of  avian  tuberculosis  is  a  different  species,  or  at  least  a 
different  variety,  from  that  of  human  tulicreulosis. 

Bacilhis  Lcpnr. — Discovered  l)y  Hansen  (1879)  in  leprous  tubercles. 
Morjiliologieally,  the  le])rosy  liacillus  resembles  very  closely  the  tubercle 
bacillus,  from  which  it  probably  cannot  be  distinguished  in  size  and 
shape.  It  presents  clear,  unstained  dots  like  those  observed  in  tubercle 
bacilli.  It  resembles  the  tubercle  bacillus  also  in  its  staining  reactions, 
the  only  important  difference  being  that  it  is  more  readily  stained  by 
aniline  dyes  than  the  tubercle  bacillus.  It  stains  well  by  Gram's  and 
A\'eigert's  fibrin  stain.  It  is  non-motile.  Although  many  observers  claim 
to  have  cultivated  the  leprosy  bacillus,  none  of  these  claims  have  been 
established,  at  least  not  to  the  satisfaction  of  most  bacteriologists.  Most 
experimenters  have  had  only  negative  results  from  the  inoculation  of 
leprous  material  into  animals.  The  positive  results  rejwrted  by  Damsch, 
Vossius  and  ]\Ielcher,  and  (Jrtman  are  o])en  to  criticism  in  their  interjire- 
tation.  The  apparently  successful  inoculation  of  a  condemned  criminal 
in  the  Sandwich  Islands  by  Arning  has  also  been  criticised  as  not  con- 
clusive. The  constant  and  exclusive  presence  of  the  bacillus  lepra  in 
leprosy  cannot  be  reasonably  interpreted  otherwise  than  that  the  liacillus 
is  the  cause  of  the  disease.  The  characteristic  bacilli  arc  present  in  enor- 
mous number  in  the  lejirous  nodules,  being  chiefly  enclosed  within  cells. 
They  have  also  been  found  in  the  lesions  of  the  disease  in  all  parts 
of  the  body.     They  are  very  rarely  in  the  blood. 

BacUliifi  Mallei. — Discovered  by  Loffler  and  Schlitz  (1882)  in  the 
lesions  of  glanders.  Somewhat  shorter  and  thicker  than  the  tubercle 
bacillus.  Presents  often  clear,  unstained  s]iaces  in  the  rods.  It  probably 
does  not  form  spores.  Decolorized  by  (xram.  Stains  with  the  usual 
aniline  dyes,  but  is  so  easily  decolorized  that  its  demonsti-ation  in  sections 
is  somewhat  difficult.  Like  the  typhoid  bacillus,  it  occurs  in  the  tissues 
especially  in  clumps.  Non-motile.  Facultative  anaerobe.  Grows  best  at 
body  temjierature,  but  is  capable  of  growth  at  room  tcmjierature.  Grows 
on  all  culture  media,  but,  as  has  been  shown  by  Theobald  Smith,  far 
better  on  acid  (non-neutralized)  than  on  alkaline  media.  Particularly 
characteristic  is  the  growth  on  potato,  on  which  the  glanders  bacillus 


BACTERIA    OF  SURGICAL  IXFECTIOyS.  331 

forms  at  first  a  transliict'iit,  amber-yellow  layer,  later  a  reddish-brown 
layer  with  discoloration  of  the  potato.  Growth  on  agar  whitish,  moist ; 
if  the  medium  be  acid,  thick  and  abundant.  The  virulence  diminishes 
in  successive  generations  in  artificial  cultures.  The  glanders  bacillus  may 
survive  in  the  dried  condition  for  three  and  a  half  months,  but  usually 
dies  within  two  or  three  weeks.  There  arc  t)l)scrvations  which  indicate 
that  it  may  survive  for  at  least  a  year  and  a  half  in  unoccupied,  infected 
staliles.  By  inoculation  of  horses  with  pure  cultures  glanders  is  pro- 
duced. The  bacillus  is  pathogenic  for  several  species  of  animals.  The 
guinea-pig  and  the  field-mouse  are  particularly  susceptible.  White  mice 
are  resistant.  The  field-mouse  dies  from  experimental  inoculation  usually 
in  three  or  four  days  with  acute  infection  and  miiuite  tubercle-like 
nodules  in  the  spleen  and  liver.  The  lesions  in  the  guinea-jiig  arc  most 
characteristic,  consisting  in  a  caseous  ulceration  at  the  scat  of  subcutaneous 
inoculation,  which,  however,  is  often  absent;  swelling  and  necrotic  sup- 
puration of  the  testicles ;  swelling  and  idceration  of  the  joints ;  and 
nodules  in  the  spleen  and  liver,  sometimes  elsewhere.  The  best  method  of 
diagnosing  a  suspected  case  of  glanders  is  to  inoculate  the  material  into  the 
peritoneal  cavity  of  a  male  guinea-pig.  In  four  or  five  days,  at  the  most 
in  eight  or  ten  days,  the  characteristic  swelling  and  infiannnation  t)f  the 
testicles  can  be  detected.  The  bacilli  arc  in  the  lesions,  but  scanty  or 
absent  in  the  blood.  Mallcin  is  a  product  derived  from  cultures  of  the 
glanders  bacillus,  and  is  analogous  in  its  properties  and  uses  to  tuberculin 
derived  from  the  tubercle  bacillus.  It  is  used  for  the  diagnosis  of  glan- 
ders in  animals,  as  tuberculin  is  used  for  the  diagnosis  of  tuberculosis. 

Bacil/itx  Aiithrdcix. — Discovered  in  the  blood  of  animals  affected 
with  anthrax  by  Pollender  (1849) ;  also  observed  by  Davaine  (1850), 
Eayer  (1851),  and  Brauell  (1857).  The  studies  upon  the  anthrax 
bacillus  laid  the  foundation-stone  of  modern  bacteriology.  The  bacil- 
lus is  1  to  1.5  II  broad  and  3  to  10  //  long.  It  grows  out  into  long 
threads  made  up  of  bacilli,  the  adjacent  ends  of  which  are  sharply  cut 
and  slightly  concave.  Not  motile.  Stains  readily  with  aniline  dyes, 
including  Gram's  stain.  Forms  spores  in  the  presence  of  oxygen,  but 
never  within  the  animal  body.  Grows  at  room  temjjerature,  best  at  body 
temperature;  does  not  grow  below  12°  C  Grows  on  all  culture  media. 
Li(]Uefics  gelatin  with  moderate  rapidity.  Colonies  on  gelatin  are  whit- 
ish, often  with  fuzzy,  irregular,  hair-like  projections.  Similar  bristle-like 
projections  often  characterize  the  growth  in  the  bne  of  i)nncture  in  gel- 
atin and  agar.  Desiccated  spores  may  survive  for  years.  Anthrax 
spores  are  usually  killed  in  four  minutes  by  boiling  temperature,  but 
they  vary  in  their  resistance,  and  may  withstand  boiling  temperature 
for  twelve  minutes  (von  Esmarch).  Some  anthrax  spores  are  killed  by 
5  per  cent,  carbolic  acid  in  two  days  ;  others  survive  for  forty  days. 
Various  modifications  of  character  of  the  anthrax  bacillus  can  be  ])ro- 
duced  by  cultivation  at  high  temperatures  (42—43°  C.)  or  by  the  addi- 
tion of  dilute  antiseptics,  the  most  Imjiortant  modifications  being  the 
production  of  an  as]iorogenic  variety  of  the  bacillus  and  the  loss  of 
virulence.  Any  degree  of  attenuation  of  virulence  can  be  produced 
down  to  com]ilete  loss.  These  attenuated  cultures  serve  as  vaccines  to 
rcn<ler  animals  insusceptible  to  anthrax.  The  anthrax  bacillus  is  a 
facultative  parasite.     It  is  in  the  highest  degree  virulent  for  mice  and 


332       GENERAL  BACTERIOLOGY  OF  SURGICAL  INFECTIONS. 

guinea-pigs,  somewhat  less  so  for  rabbits.  Sheep  and  cattle  are  the  ani- 
mals which  sui!er  the  most  from  the  natural  disease.  Swine,  dogs,  and 
most  birds  are  immune.  Kats  and  pigeons  are  resistant,  but  not  wliolly 
insusee|)til)le,  to  anthrax.  Man  does  not  rank  among  those  higlily  sus- 
ceptible to  the  disease.  Infection  may  occur  from  the  skin,  intestine,  or 
lungs.  In  small  susceptible  animals  experimental  anthi'ax  is  a  septi- 
caemia with  abundant  bacilli  in  the  blood.  In  man  anthrax  usually 
occurs  with  localized  inflammations  at  the  seat  of  invasion  (malignant 
pustule,  intestinal  anthrax,  wool-sorter's  disease).  In  some  cases  the 
disease  remains  localized ;  in  others  general  infection  and  multiple 
localization  occur. 

Aefinoinyces,  or  Bay  Funr/Hs. — First  recognized  as  a  living  organism 
by  Bollinger  in  1877  in  actinomycosis  or  lump-jaw  of  cattle;  obsei'ved 
in  man  in  1845  by  B.  von  Ijangenbeck,  whose  disco\'ery,  however,  was 
not  published  until  1878,  when  it  was  mentioned  by  J.  Israel,  to  whom 
belongs  the  credit  of  first  recognizing  the  ray  fungus  as  a  distinct  micro- 
organism pathogenic  tor  man. 

There  are  various  species  or  varieties  of  the  genus  actinom3-ces,  but 
we  are  al)le  with  our  present  methods  to  differentiate  them  from  each 
other  only  imperfectly.  Actinomyces  honiinis,  which  is  probal)ly  iden- 
tical with  actinomyces  bovis,  is  the  oidy  s])ecies  which  will  lie  considered 
here.  Authorities  are  not  agreed  as  to  the  botanical  j)osition  of  this 
organism,  but  most  writers  now  regard  it  as  belonging  to  the  group  of 
the  more  highly-organized  pleomorphic  bacteria,  and  allied  to  clado- 
thrix  or  streptothrix.     Some,  however,  class  actinomyces  with  the  fungi. 

Actinomyces  is  the  cause  of  a  chronic  inflammatory  affection,  pre- 
senting sometimes  the  characters  of  an  abscess,  at  other  times  more 
those  of  a  tumor,  with  suppurating  tracts  and  cavities.  The  })rescnce 
of  the  parasite  can  usually  be  detected  a\  ith  the  naked  eye  by  finding  in 
the  pus  small  yellowish  granules.  These  granules  vary  in  size,  shape, 
and  color.  They  are  usually  described  as  about  the  size  of  a  jiin's  liead. 
They  may  be  much  smaller,  even  microscopic  in  size,  and  exceptionally 
they  may  be  massed  together  in  clumps  the  size  of  a  pea.  To  the  naked 
eye  they  generally  appear  round,  l)ut  microscopicall}'  their  contours  are 
seen  to  be  irregular.  They  may  be  grayish  and  translucent  like  sago 
particles,  or  opaque  gray  or  white,  or  yellow,  greenish-yellow,  brownish, 
even  black.  Bostroem  has  demonstrated  that  these  various  tints  depend 
partly  ujion  tlie  stage  of  develoj)ment  of  the  organism,  the  younger  forms 
witliout  club-like  terminations  being  pale  and  transparent.  The  black 
granules  have  been  observed  only  in  intestinal  actinomycosis.  The  con- 
sistence of  the  granules  or  cokmies  in  their  early  stage  of  development 
is  soft  and  gelatinous ;  later  it  becomes  firm  and  compact,  and  it  may 
become  hard  and  gritty  from  deposit  of  lime  salts  in  the  old,  degen- 
erated colonies.  The  young,  translucent  bodies  are  most  abundant  in 
foci  of  rapid  softening  and  liciuefaction  of  the  tissues.  The  number  of 
the  bodies  present  in  the  pus  varies  in  different  cases.  They  may  be  so 
few  as  to  require  long  search  to  find  them  ;  usually  they  are  numerous, 
and  sometimes  there  are  myriads  of  them. 

These  characteristic  granules,  visible  to  the  naked  eye,  are  colonies  of 
the  actinomyces  or  clumps  of  colonies.  The  youngest  colonies  are  not 
visible  to  the  naked  eye.     These  consist  of  a  central  interlacing  mass  of 


BACTERIA    OF  SURGICAL  INFECTIONS.  333 

braiicliino;  threads  \Aitli  radiating  projections  of  threads.  The  most  coni- 
nioii  and  characteristic  appearances  are  found  in  okler  colonies  (called  by 
the  Germans  "  Drnseu  ").  Here  we  find  the  centre  of  each  colony  com- 
posed of  extremely  fine  interlacing  threads  and  small  round  bodies 
resembling  cocci,  and  the  periphery  made  up  of  bulbous,  club-like 
terminations  of  the  threads.  It  is  jiarticularly  this  outer  ring  of  radi- 
ating, club-shaped  projections  which  gives  to  these  bodies  their  most 
diagnostic  feature.  It  requires  careful  study  and  differential  staining  to 
make  out  the  real  structure  of  the  actinomyccs  bodies.  Ordinarily,  the 
central  ])art  of  the  colony  appear,^  simply  as  a  confused  granular  and 
finely-filamentous  mass.  It  has,  however,  been  shown  to  consist  of 
extremely  delicate  rods  and  threads,  which  branch  dichotomouslv,  and 
which,  ari'anged  somewhat  loosely  in  the  centre,  become  more  densely 
interwoven  and  larger  toward  the  periphery,  and  there  pass  in  a  radiating 
manner  one  into  each  of  the  swollen  bulbs.  This  Ijulbous  swelling  ap- 
pears to  be  due  to  an  accumulation  of  a  clear  hyaline  material  in  the 
sheaths  of  the  fibres,  and  to  represent  only  an  involution  or  degenera- 
tive condition,  not  forming  an  essential  part  of  the  living  structure  of 
the  parasite.  The  hyaline  bulbs  may  present  an  appearance  of  concentric 
striation,  and  each  one  may  break  up  into  finger-like  jirojections  or  have 
somewhat  the  appearance  of  a  pine  cone.  They  may  become  calcified. 
These  are  all  degenerative  changes.  Both  within  and  outside  of  the 
threads  are  seen  round  bodies  like  cocci,  which  are  considered  by  Bos- 
troem  to  be  spores,  but  whose  nature  is  undetermined.  They  may  be 
very  abundant,  so  that  the  central  part  of  the  colonies  consists  almost 
mIioIIv  of  these  round  granules  with  very  few  threads.  Cases  of  actino- 
mycosis occur  exceptionally  in  which  there  are  no  bulbous  endings  to 
the  threads  composing  the  colony.  In  addition  to  the  colonies,  numer- 
ous bacilli  are  often  foiuid  scattered  throughout  the  inflammatory  nod- 
ides  of  actinomycosis.  Pyogenic  cocci  are  frequent  secondary  invaders 
in  actinomycotic  growths.  Gram's  and  Weigert's  fibrin  stain  and  luemat- 
oxylin  and  eosin  can  be  used  to  advantage  in  the  microscopical  study  of 
actinomyccs. 

Many  investigators  claim  to  have  cultivated  the  ray  fungus.  There 
is  so  much  discrepancy  in  their  descriptions  of  the  characters  and  con- 
ditions of  these  cultures  that  we  cannot  recognize  all  of  them  as  genuine 
cultures  of  actinomyces.  Probably  the  most  confidence  is  to  be  given  to 
the  cultures  obtained  by  J.  Israel  and  M.  Wolff.  They  found  that  actin- 
omyccs grows  best  anacrobically  and  at  the  temperature  of  3o°-37°  C. 
They  used  chiefly  as  their  culture  media  nutrient  agar  and  hen's  and 
pigeon's  eggs.  The  growth  is  slow  and  in  the  form  of  drj^,  small,  pro- 
jecting, irregular  colonies,  which  arc  at  first  gray  and  ti'anslucent,  and 
later  opaque.  On  agar  actinomyces  grows  chiefly  in  the  form  of  rods — 
in  eggs,  in  the  form  of  interlacing,  branching  thi'eads.  Bulbous  termina- 
tions of  the  threads  are  not  tibserved  in  the  cultures. 

The  majority  of  experimenters  have  obtained  only  negative  results 
in  attempting  to  produce  actinomycosis  experimentally  in  animals  by 
inoculation  of  material  containing  the  specific  micro-organism.  Bos- 
troem  in  his  elaborate  article  on  actinomycosis  considers  all  of  the  positive 
results  reported  up  to  the  date  of  its  publication  (1890)  as  inconclusive. 
Since  that  date,  however,  several  observers  have  reported  more  or  less 


334       GENERAL  BACTERIOLOGY  OF  SURGICAL  INFECTIONS. 

success  in  producing  the  disease  experimentally ;  and  here,  again,  the 
results  obtained  by  Israel  and  Woltf'  are  the  most  noteworthy.  They 
succeeded  by  introduction  of  their  pure  cultures  of  actiuomyces  into  the 
peritoneal  cavity  of  rabl)its  and  jj;uinea-pigs  in  producing  siuall  nodules 
in  the  ])eritoncuni  and  spleen.  These  nodules  contained  typical  actiuo- 
myces colonies  with  the  bulbous  rays.  Further  investigation  is  needed 
regarding  the  experimental  inoculation  of  actiuomyces. 

Infection  both  of  human  beings  and  of  cattle  with  actinomycosis  has 
been  often  traced  to  the  penetration  of  vegetable  grains  (wheat,  barley, 
oats)  or  bits  of  vegetable  fibre  into  tlie  tissues.  The  portal  of  entry  is 
frequently  the  mouth,  particularly  the  neighljorhood  of  the  teeth,  but  it 
may  be  through  a  wound  of  the  skin  or  through  the  mucous  membranes 
of  the  tln-oat,  respiratory  tract,  oesophagus,  intestine,  or  middle  ear. 
It  is  not  always  possible  to  find  the  jjoint  of  entrance,  as  this  may 
heal  completely. 

Various  clinical  types  of  actinomycosis  are  recognized  according  to 
the  seat  of  tlic  afl'ection,  such  as  actinomycoses  of  the  jaws  and  else- 
where about  the  head  and  neck,  of  the  lungs,  the  pleura,  the  vertebrse, 
the  intestine  and  other  abdominal  organs,  the  brain,  the  middle  ear,  the 
skin.  There  is  usually  a  single  localization,  but  there  may  be  multiple 
foci,  ])resenting  sometimes  anatomical  and  clinical  characters  of  pyemia. 

The  histological  changes  are  characterized  by  necrosis  and  liquefaction 
of  tissue  with  emigration  of  white  blood-corpuscles  as  the  inunediate 
effect  of  the  parasite,  and  a  secondary  reactive  inflammation  in  the  form  of 
vascidar  granulation  tissue.  By  some  the  changes  are  considered  to  be 
more  closely  allied  to  those  of  infectious  granulomata  than  of  ordinary 
inflammation.  In  some  cases  the  process  is  rapid  and  destructive,  with 
little  new  formation  of  tissue,  and  with  the  pnxluetion  of  large  abscesses  j 
in  others  the  affection  may  be  very  chronic,  of  limited  extent,  and  encap- 
sulated by  new  growth  of  tissue.  When  bone  is  involved  there  may  be 
formed  osteophytes  and  sclerosing  ostitis,  or  there  may  be  simply  destruc- 
tion without  new  formation  of  bone.  Metastases  do  not  appear  to  occur 
in  the  lymphatic  glands  comnuniieating  by  the  lymph-current  with  a 
j)rimary  focus  of  actinomycosis. 

Madura  disease,  or  mycetoma,  both  in  the  melanoid  and  the  ochroid 
varieties,  has  been  shown  by  Kanthack  to  be  due  to  a  parasite  very 
closely  allied  to  the  ordinary  actiuomyces  hominis.  Kanthack  considers 
that  the  parasite  is  simjily  a  variety  of  the  ordinary  actiuomyces. 


SYMPTOMS,  DIAGNOSIS,  AND  TREATMENT  OF 
INFLAMMATION,  ABSCESS,  ULCER,  AND 
GANGRENE. 

By  CHAS.  B.  NANCREDE,  A.  M.,  M.  D. 


Inflammation  is  "the  succession  of  changes  which  occur  in  a  liv- 
ing tissue  when  it  is  injured,  provided  the  injury  is  not  of  sucli  a  degree 
as  at  once  to  destroy  its  vitality,  these  changes  tending  to  the  repair  of 
tissues  or  the  neutralization  or  removal  of  tlie  jirimarv  niicrohic  cause." 

This  definition  indicates  that  there  are  two  distinct  forms  of  inflam- 
mation. The  first  is  a  purely  regenerative  process,  which,  occurring  in 
aseptic  tissues,  is  productive  of  cell-proliferation,  these  new  cells  devel- 
oping into  a  normal,  ]iernianent  tissue.  It  must  never  be  forgotten 
that  the  processes  of  infianunation  are  essentially  the  sanie  in  the  vascu- 
lar, the  soft  and  the  hard,  the  superficial  and  the  deep  tissues. 

Acute  Simple  or  Plastic  Inflammation. 

Because  this  is  a  purely  regenerative  process  some  contend  that  it 
should  not  be  described  as  a  disease.  While  this  is  partly  true,  aseptic 
inflammation  must  be  here  studied,  not  only  because  at  the  outset 
microbic  inflammation  presents  similar  microscopic  and  macroscopic 
phenomena,  and,  when  recovery  ensues,  healing  occurs  by  the  same 
histological  changes,  but  also  to  learn  how  microbes  interfere  with  re- 
generation, and  how  the  surgeon  can  minimize  their  malign  effects  when 
he  cannot  wholly  exclude  them. 

Redness,  heat,  ])ain,  swelling,  and  impaired  function,  the  classical 
symptoms  of  inflammation,  can  rarely  be  all  detected  except  when  the 
superficial  parts  are  aflected.  The  redness,  at  first  uniform,  fading 
into  the  hue  of  the  surrounding  healthy  parts,  temporarily  disappears 
on  pressure,  but  later  becomes  mottled  with  patches  of  a  deeper  hue 
which  are  uninfluenced  by  pi'cssure.  The  uniform  tint  is  from  excess 
of  blood  in  the  vessels,  while  the  mottling  results  either  from  the 
diapedesis  of  red  cells,  their  escape  by  rupture  of  the  capillaries  into 
the  tissues,  or  from  clotting  (tlirombosis)  of  blood  in  the  vessels ; 
hence  pressure  influences  the  first,  but  not  the  second,  condition.  To 
this  excess  of  blood  is  also  due  the  increased  temperature  of  the  part, 
although  some  allege  tliat  chemico-vital  phenomena  account  for  part 
of  the  heat :  it  is  doubtful  if  tlie  temperature  of  an  inflamed  part  is 
ever  higher  tlian  tliat  of  the  blood  in  the  heart  of  the  individual,  in 
whom,  it  must  l)e  remembered,  the  whole  mass  of  the  blood  is  warmer 
than  in  health  because  of  the  fcbii/e  heat.    Swelling  also  is  at  first  due  to 

335 


336  DIAGNOSIS  AND   TREATMENT  OF  INFLAMMATION. 

excess  of  blood,  but  soon  the  distended  blood-vessels  jiermit  the  escape 
of  serum,  then  licjuor  sanguinis  and  leucocytes,  the  latter  migrating 
through  the  vessel-walls  l)y  virtue  of  their  amoeboid  movements.  At 
the  jjcriphery  of  the  inflammation  little  but  scrum  or  some  licjuor  san- 
guinis distends  the  tissues,  which,  if  the  jjart  be  su])erficlal,  gives  rise  to 
the  symj^tom  cedema — /.  c.  the  tissues  remain  pitted  for  some  time  after 
firm  pressure  has  been  made,  and  the  part  is  often  paler  than  normal. 
This  succulence  of  the  tissues  has  been  experimentally  demonstrated  by 
examining  the  amount  of  fluid  returned  by  the  lymjthatics  leading  from 
an  inflamed  area,  as  compared  with  that  poured  out  wlien  the  vessels  of 
the  corresponding  meml)er  were  divided  :  the  neighboring  lymphatic 
glands  are  often  enlarged  and  tender  from  the  ])assage  of  this  excess 
of  lymph,  which  contains  irritating  materials.  Pain  results  from  the 
stretching  of  the  nerves  due  to  swelling,  from  their  compression  by 
exudates,  their  exalted  sensibility  from  increased  vascularity,  and  from 
the  chemical  irritation  of  ptomaines  or  toxalbumins  when  present.  As 
the  microscopic  phenomena  of  inflammation  are  described  elsewhere,  it 
is  only  necessary  to  advert  for  clinical  jiurposes  to  certain  points — viz. 
that  after  the  primary  acceleration  of  the  blood-current  a  gradual  "  slow- 
ing "  of  this  occurs,  allowing  germs  as  well  as  leucocytes  to  accumulate 
in  the  circumferential  colorless  current ;  that  from  this  time  on  the 
white  blood-cells  migrate  in  increasing  numliers  until  the  focus  of  in- 
flammation is  crowded  with  leucocytes — indeed,  the  cell-islets  of  the 
tissues  are  jjractically  replaced  by  the  migrated  white  Ijlood-corpuscles, 
with  a  varying  number  of  red  cells ;  that  next  stasis  of  the  blood-current 
occurs,  but  that  if  the  exciting  cause  of  the  inflammation  ceases  all  these 
processes  will  be  reversed,  for  the  blood  which  is  at  rest  is  not  clotted. 
Thus  the  central  mass  of  red  cells  first  oscillates,  then  the  current  com- 
mences, the  white  cells  slowly  mingle  with  the  central  column  of  red 
cells,  the  migrated  leucocytes  pass  off  through  tlie  lymphatics  or  disin- 
tegrate, and  their  remnants  are  disposed  of  by  the  same  route,  together 
Avith  the  excess  of  fluid,  the  parts  being  left  in  their  normal  condition. 

When  these  changes  are  rapidly  effected  the  inflannnation  is  said  to 
terminate  by  "  delitescence ;"  when  the  tissues  have  to  be  cleared  of  the 
migrated  cells  by  their  disintegration,  "  resolution  "  is  the  term  employed 
for  this  slower  process.  Should  these  favorable  changes  not  take  place, 
permanent  stasis  must  occur,  thrombi  forming  in  the  vessels;  the  effused 
liquor  sanguinis  coagulates  in  the  tissues,  and  the  inflamed  area,  from  the 
combined  effect  of  the  original  injury,  plugging  of  its  vessels,  accumula- 
tion of  fluids  and  of  cells,  is  deprived  of  j^roper  nutriment  and  disap- 
pears by  absorption,  leaving  nothing  but  a  mass  of  young  cells  held 
together  with  a  small  amount  of  intercellular  cement.  That  this  cellular 
mass  may  develop  into  permanent  tissue,  its  due  blood-supply  must  be 
furnished,  which  comes  by  the  ingrowth  of  capillary  loops  springing 
from  the  blood-vessels  of  the  surrounding  undamaged  tissues :  in  other 
words,  fullj'-formed  granulations  are  formed.  When  the  bulk  of  the 
cells  develops  into  fibrous  tissue  a  subcutaneous  scar  results,  with  its 
ulterior  evil  effects,  but  when  less  sear-tissue  forms,  and  it  is  somewhat 
diffused  throughout  the  part,  the  condition  is  termed  "fibroid"  or 
"  chronic  "  thickening. 

If  during  the  first  stages  of  inflammation,  when  the  vital  resistance  is 


INFECTIVE  INFLAMMATION.  337 

lowered,  microbes  reach  the  tissues,  an  infective  inflammation  will  result, 
but  if  their  advent  be  delayed  until  tlie  second  stage,  that  of  fully- 
formed  granulation  tissue,  be  reached,  mierobic  invasion  is  always  vig- 
orously, and  often  successfully,  resisted.  When  the  so-called  third  stage 
of  inflammation  has  been  attained — i.  e.  that  of  a  mature  but  low-grade 
tissue,  possessing  for  the  time  an  excessive  vascular  supply — microbes 
can  exert  no  more  harmful  influence  than  upon  any  other  similar  tissue. 

Infecti'Ve  Inflammation. 

This  is  a  result  of  the  interference  produced  by  microbes  with  the 
processes  of  repair  always  attemjited  by  nature,  and  tlie  products  of 
tissue-metamorphosis  do  not  undergo  development  intt)  a  permanent 
tissue,  but  sutt'er  from  degenerative  cliangi's.  Eitlier  tiie  ptomaines, 
peptonizing  ferment,  or  certain  toxalbumins  are  the  direct  causes,  not 
the  germs  themselves.  These  substances  produce  coagulation-necrosis, 
directly  or  indirectly  solution  of  the  intercellular  cement  binding  the 
exudate  together,  and  the  fatty  degeneration  and  death  of  the  cells, 
these  latter  l^eing  gradually  absorbed  after  cessation  of  the  cause,  as  in 
certain  cases  of  tuberculosis,  or,  dying  more  rapidly,  mingle  with  the 
pus-cells  whicii  float  in  the  liquefied  intercellular  cement  mingled  with 
the  serous  exudate — i.  e.  the  liquor  purin. 

Suppuration  is  now  said  to  be  establislied.  When  this  occurs  upon  a 
free  surface,  as  that  of  the  skin  or  a  mucous  membrane,  with  loss  of  sub- 
stance, the  process  is  termed  "  ulceration  ;"  tiie  resultant  loss  of  substance, 
an  "ulcer."  Occurring  distinctly  circumscribed  in  tlie  depths  of  the 
tissues,  it  is  called  an  "  abscess,"  or  wlien  not  so  sharply  defined  from  the 
surrounding  tissues,  a  "  purulent  collection."  The  pus  being  evacuated 
by  nature  or  art,  if  death  does  not  result  from  absorption  of  ptomaines 
or  toxines,  the  parts  revert  to  their  normal  condition,  except  wiiere  the 
tissues  have  been  destroyed  in  the  suppurative  process :  here  a  scar  com- 
posed of  newly-formed  cijiiiiective  tissue  forms. 

Tlie  rapidity  with  which  the  inflammatory  process  passes  through  its 
various  phases — i.  e.  whether  it  is  acute,  subacute,  or  chronic — depends 
first  upon  the  nature  of  the  micro-organisms  causing  it.  Thus  infection 
by  the  ordinary  germs  of  su])puration  or  by  those  of  gonorrhoja  pro- 
duces an  acute  process ;  the  germs  of  glanders  induce  a  subacute  or 
clininic  inflammation,  while  tliose  of  tubercle  produce  a  chronic  inflam- 
mation. Tiie  number  of  any  form  of  germ  present  influences  tlie  rapid- 
ity and  severity  of  the  inflammation,  for  healthy  tissues  can  inhibit  the 
growth  of,  or  entirely  resist  the  action  of,  and  remove,  germs,  if  not  too 
numerous.  A  few  of  the  minute  processes  must  be  briefly  reviewed  in 
order  to  understand  mierobic  inflammation. 

The  primary  acceleration  and  increased  volume  of  tlie  blood-current 
prevent  mural  implantation  of  germs  or  sweep  away  sucii  as  liave  be- 
come attached  to  the  vessel-walls.  During  the  second  stage — i.  e.  tliat  of 
the  formation  of  granulation  tissue — this  process  is  successfully  carried 
out  around  the  primary  infected  area,  but  the  pejjtonizing  ferment  or  the 
ptomaines  destroy  this  boundary-area,  and  continue  to  do  so  until  tlie 
virulence  of  the  cause  is  exhausted.  Tiien  the  last-formed  granulations, 
surrounding  the  pus  or  tlie  specific  tissue,  produce  healing  of  the  cavity 

Vol.  I.— 22 


(^ 


338  DIAGNOSIS  AND   TREATMENT  OF  INFLAMMATION. 

after  tlie  pus  oi-  liquefied  tissue  with  the  germs  has  been  evacuated.  In 
certain  instances  of  cin-oni(^  infective  processes,  as  tubercle,  under  favor- 
able conditions,  retrograde  processes  do  not  occur,  the  embryonal  cells 
becoming  converted  into  scar-tissue. 

Certain  inicrobic  jirocesses,  such  as  tubercle  or  acute  osteomyelitis,  are 
not  commonly  excited  by  severe  injuries,  but  by  slight  ones  producing  a 
locus  mlnorls  n'sidcntia'.  The  increased  afflux  of  blood  induced  by  a 
severe  injury,  and  the  cellular  exudate,  some  of  whose  elements  are 
doubtless  phagocytes,  probably  ex])lain  this.  Again,  the  numerous 
wliite  cells  by  their  power  of  incorporating  foreign  bodies  serve  to 
remove  after  such  injury  germs  which  are  destroyed  by  the  nucleins  of 
the  blood  or  arc  excreted  l)y  the  kidneys.  The  imperfectly  vascularized 
granulation  tissue  resulting  from  such  chronic  infective  inflammations  as 
actinomycosis,  tubercle,  etc.  predisposes  to  supjiuration  by  preparing  a 
soil  for  secondary  infection  with  pyogenic  organisms. 

To  recapitulate  :  the  terminations  of  inflammation  are,  for  the  ])lastic 
variety,  delitescence,  resolution,  and  fibroid  thickening ;  for  infective 
inflammations,  suppuration  or  ulceration.  Gangrene  is  not  a  termination 
of  any  form  of  inflammation,  but  a  consequence  and  an  accidental  result 
of  the  inflammatory  process. 

The  old  view,  that  inflammation  involved  an  increase  in  the  nutritive 
activity,  is  no  longer  tenable  for  the  infective  forms,  lowered  vitality 
being  the  predisposing  cause,  and,  later,  the  efficient  cause  of  their  con- 
tinuance and  spread  :  this  fact  is  the  key  to  their  treatment. 

Inflannnation  is  primarily  a  molecular  change  which  may  be  due  to 
microbic  ferments,  ptomaines,  or  toxallnnnins  circulating  in  the  blood, 
or  to  traumatism  so  damaging  the  tissues  tiiat  the  changes  of  a  plastic 
inflammation  will  result ;  or,  from  the  physical  conditions  produced, 
gei'ms,  entering  elsewhere,  will  accumulate,  producing  some  variety  of 
microbic  inflammation. 

Precisely  similar  inj\iries  inflicted  upon  different  individuals,  or  upon 
the  same  individual  before  and  after  an  attack — say,  of  rubeola' — will  pro- 
duce in  one  instance  nothing  but  a  plastic  process,  in  another  a  grave 
microbic  inflammation.  Precedent  conditions  which  of  themselves  are 
incapable  of  producing  evil  in  the  absence  of  some  exciting  cause,  as  a  blow 
or  wound,  thus  favor  the  production  of  inflammation  ;  these  conditions 
are  termed  prcdisposinf)  causes.  They  act  by  so  lowering  the  vitality 
of  the  parts  as  to  render  them  unable  to  resist  deleterious  influences. 
Among  the  most  common  are  the  impoverishment  of  the  l)lood  and  the 
weakened  heart's  action  resulting  from  insufficient  or  improper  food, 
the  former  lowering  the  tissue-resistance  to  microbes,  the  latter  so  slow- 
ing the  cinndation  as  to  favor  the  accumulation  of  germs.  The  acute 
antemia  and  weakened  heart  produced  by  hemorrhage  act  similarly.  The 
weak  heart-action  often  seen  in  old  age  favors  stasis,  and  thus  aceunnda- 
tion  of  germs  if  any  gain  access  to  the  circulation,  which  the  ill-nourished 

'  It  is  important  to  remembpr  th.it  not  only  is  inflannnation  modified  by  certain  erup- 
tive ailments,  but  also  tliat  inflammation  following  operation  may  predispose  to  them. 
Thus,  scarlatina  sometimes  promptly  follows  upon  operation  where  no  known  exposure 
has  occurred,  tlie  lowered  somatic  vitality  favoring  the  development  of  the  eruptive 
disease.  Of  course  reference  is  not  liere  made  to  the  scarlatinoid  eruptions  of  sepsis,  but 
to  the  genuine  eruptive  fever,  scarlatina.  For  the  pseudo-scarlatina  the  reader  is  referred 
to  the  section  on  Septicemia,  etc. 


INFECTIVE  INFLAMMATION.  339 

tissues  cannot  resist.  The  dejiravation  of  tlie  blood  by  the  retention  of 
the  excreta  in  ehronic  renal  and  hepatic  diseases,  as  well  as  in  gout, 
svphilis,  and  diabetes,  predisposes  to  inflammations.  The  vasomotor  dis- 
turbances following  certain  nerve-injuries  lead  to  such  imperfect  nutri- 
tion and  tendency  to  stasis  that,  as  is  well  known,  inflammation  readily 
occurs.  'The  relation  of  the  so-called  strumous  diathesis  is  difficult  to 
understand  unless  upon  the  assumption  that  in  some  individuals 
there  exists  a  tendency  to  excessive  cellular  proliferation  upon  trivial 
injury.  The  numerous  cells  so  outstrip  their  nutrient  supply  that  case- 
ous degeneration  is  i)rone  to  occur,  pro\-iding  an  excellent  culture- 
medium  for  the  germs  of  tubercle  primarily,  and  for  those  of  pus  later. 

The  exciting  causes  of  inflammation  are  usually  stated  to  be  direct  vio- 
lence— ('.  e.  mechanical  injuries — heat,  cold,  electricity  (as  a  cauterizant), 
tension,  acids,  or  alkalies  ;  but  violence  per  se  can  only  induce  primarily  a 
plastic  inflammation,  nor  will  the  other  agencies  do  more  unless  infection 
by  micro-organisms  ensues  ;  so  that  the  only  exciting  cause  for  inflam- 
mations which  arc  not  simply  the  conservative  processes  of  repair  (/.  c. 
plastic  inflammation)  are  the  ptomaines,  peptonizing  ferments,  or  tox- 
albumins  resulting  from  the  development  of  micro-organisms,  direct 
violence  being  rclegateil  to  the  category  of  jjredisposinr/  causes.  That 
healthy  tissues  can  inhil)it  tlie  growth  of  or  destroy  numerous  bacteria 
must  never  be  forgotten,  this  truth  reconciling  many  apparently  con- 
tradictory facts  as  to  the  relation  of  micro-organisms  and  inflammation. 

A  broad  distinction  must  be  made  between  the  micro-organisms  of 
putrefaction  and  those  which  are  infective  or  pathogenic,  the  former 
living  only  in  dead  or  dying  tissues  and  generating  various  poisonous 
ptomaines,  the  latter  capable  of  developing  in  living  tissues,  thriving  in 
tlie  innermost  recesses  of  organs  if  carried  there  by  the  lyinjih  or  blood, 
and  producing  wherever  located  each  its  special  ferment,  toxalbumin, 
etc.  The  entrance-point,  or  "  infection-atrium,"  is  usually  a  wound, 
especially  a  foul,  ill-drained  one,  but  germs  may  enter  through  trivial 
lesions  of  the  cutaneous,  respiratory,  or  alimentary  tract. 

Treatment. — Tliis  should  be  preventive  when  feasible  :  the  appro- 
priate measures  will  be  found  in  the  section  on  the  aseptic  and  antise|)tic 
treatment  of  wounds.  The  curative  treatment  must  first  aim  to  remove 
the  secondary  causes  which  maintain  the  process,  and  next  to  minimize 
the  inevitable  damage.  Kest  in  its  widest  sense  must  be  secured — by 
quiet  of  the  jiarts  obtained  by  splints  or  other  dressings  ;  by  the  drainage 
eftected  by  incision  and  position,  thus  securing  undisturbed  contact  of 
healing  parts ;  by  relief  of  tension,  effected  by  the  preceding  measures 
supplemented  by  incisions  other  than  those  for  drainage ;  by  lessening 
the  force  and  frequeilcy  of  the  heart's  action  ;  by  diminishing  the  blood- 
supply  by  local  astringents ;  by  evacuation  of  irritating  materials,  as 
putrid  urine,  blood,  or  pus;  by  the  use  of  non-irritating  dressings; 
and  by  the  recognition  and  treatment  of  such  predisposing  conditions 
as  rheumatism,  syphilis,  gout,  and  tubercle.  If  these  measures  do  not 
result  in  the  subsidence  of  the  inflammation,  the  second  indication — viz. 
to  lessen  the  extent  of  the  inevitable  damage — must  be  carried  out  by 
measures  adapted  to  improve  the  nutrition  of  the  tissues,  thus  prevent- 
ing local  or  somatic  death. 

The  alinormal  blood-pressure  maintains  the  dilatation  of  the  vessels 


340  DIAGNOSIS  AND   TREATMENT  OF  INFLAMMATION. 

and  the  accumulation  and  esca])e  of  licjuid  and  solid  exudates,  which  by 
their  mechanical  pressure  on  the  tissue-cells  interfere  with  their  nutri- 
tion. A  lessening  of  the  blood-sujjply  will  diminish  all  this  and  the 
tendency  to  stasis.  The  measures  already  detailed  will  effect  much,  but  es- 
])ecially  treatment  of  the  dyscrasia  acting  as  a  predisposing  cause.  Pain 
nuist  l)e  relieved,  because  it  can  alone  increase  local  vascularity,  induce 
rise  of  temperature,  ])revent  sleep  and  ingestion  of  food,  thus  dii-ectlv 
lowering  vitality ;  moreover,  severe  pain  maintains  shock  and  probablv 
actually  kills  the  very  old  or  very  young.  The  rapidity  of  cure  is  often 
dependent  upon  the  relief  of  pain  and  irritati(»n.  A  close  watch  must  be 
kept  upon  the  action  of  the  kidneys,  skin,  and  liver — viz.  the  emunctories. 
AVhile  too  free  movements  of  the  l)0wels  must  be  checked,  in  sejjtic  con- 
ditions this  attempt  of  nature  to  evacuate  peccant  matters  must  be  most 
cautiously  interfered  with. 

From  what  precedes  it  is  evident  that  both  local  and  general  meas- 
ures are  available,  the  former  sometimes  being  alone  requisite. 

Local  Measures. — Rest,  com})lete  and  physiological,  must  be  main- 
tained. Elevation  of  the  part,  by  interfering  ^\  ith  the  access  of  arterial 
blood,  favoring  the  egress  of  venous  blood,  and  aiding  drainage  by  the 
lymphatics,  is  very  useful.  Cold  is  effective,  Ijut  demands  caution,  and 
is  best  used  as  a  preventive  before  stasis  has  taken  place,  although  later 
it  may  do  good  by  lessening  the  congestion  at  the  periphery,  even  when 
stasis  has  occurred  at  the  focus.  It  is  usually  only  harmful  in  the  later 
stages,  especially  if  strangulation  of  the  tissues  exists,  when  cold  may 
determine  mortification. 

As  cold  can  only  act  through  the  vasomotor  nervous  system,  first 
causing  contraction  of  the  arterioles,  then  of  the  capillaries  and  veins, 
indirectly  relieving  intravascular  pressure,  it  is  only  necessary  to  impress 
the  sensory  nerves  of  the  part  by  moderate  cokl,  because  intense  cold 
directly  lowers  the  vitality  of  the  tissues  and  jiromotes  adhesion  of  the 
leucocytes,  precipitating  stasis,  as  occurs  in  frost-bite  :  moderate  cold 
doubtless  renders  the  amoeboid  action  of  the  leucocytes  more  sluggish, 
thus  opposing  diapedesis.  To  be  effective  it  must  l)e  continuous.  As  moist 
cold,  water  at  the  proper  temperature  can  be  allowed  to  drip  on  the  parts 
— covered  with  lint  or  cotton  to  diffuse  the  fluid  over  a  wider  area — or 
can  be  conducted  to  this  covering  from  the  vessel  by  capillarity,  using 
strips  of  lint  or  gauze.  The  \\ater  may  contain  any  germicide  desired, 
this  measure  being  often  desirable  if  sujjpuration  is  present.  Dry  cold 
can  be  applied  by  ice-bags  or  bladders  or  by  Leiter's  coils,  which  can  be 
extemporized  out  of  a  few  yards  of  small  rubber  tubing  wired  into  shape 
or  sewed  to  a  piece  of  muslin. 

Heat  possibly  acts  derivatively  by  dilating  the  peripheral  capillaries 
and  those  of  the  skin,  but  the  chief  benefit  derived  from  its  use  is  that, 
when  suppuration  cannot  Ite  avoided,  it  hastens  the  ])rocess,  tending  to 
localize  it  by  promoting  the  flow  of  blood  and  stinudating  the  amoeboid 
action  of  the  leucocytes,  causing  their  rapid  aecumulati(jn  at  the  focus  of 
inflammation.  When  resolution  is  possible  the  increased  blood-supply 
caused  by  the  application  of  heat  favors  absorption  of  the  liquid  exu- 
dates, and  the  increased  anifeboid  activity  of  the  wandering  cells  enables 
them  to  migrate  through  the  lymph-spaces,  thus  clearing  the  tissues  of 
the  solid  exudate. 


INFECTIVE  INFLAMMATION.  341 

Heat  may  be  employed  dry  by  hot- water  bags,  by  bottles,  by  heated 
bags  of  salt,  or  by  Leiter's  tubes ;  moist  heat  can  be  employed  by  irri- 
gation or  by  some  form  of  poultice — /.  e.  some  coherent  sulistance,  as 
flaxseed  meal,  cotton  batting,  etc.,  wliicli  will  retain  heat  and  moisture. 
Poultices,  other  tlian  wet  absorbent  antiseptic  dressings  covered  witli 
oiled  silk  or  rubber  tissue,  sliould  never  be  employed  after  a  suppurating 
focus  has  been  opened  or  when  Nature  may  evacuate  this  at  any  moment, 
since  asepsis  would  be  impossible. 

Bloodletting. — To  be  efficient,  this  must  de})lete  the  vascular  area 
involved,  even  at  a  distance.  Thus,  blood  drawn  over  the  temples  is 
removed  from  veins  which  communicate  witli  the  ophthahnic  vein  ; 
leeches  o\er  the  mastoid  process  abstract  blood  from  the  radicles  t)f  tiie 
mastoid  vein,  which  empties  directly  into  the  lateral  sinus.  Local  bleed- 
ing can  do  good  only  in  the  earlier  stages  of  inflammation,  when  stasis 
is  about  to  occur  or  has  just  occurred — /.  e.  before  thrombosis  has  taken 
place.  Employed  at  this  stage,  the  stagnant  blood  can  be  seen  to  resume 
its  flow  through  the  occluded  vessels,  and  a  rapid  reversal  of  the  inflam- 
matory processes  takes  ))lace.'  Leeching  or  cn])piug  is  the  best  means 
for  the  local  abstraction  of  blood.  Incisions  are  useful  to  relieve 
mechanical  tension,  to  give  vent  to  exudates,  and  to  remove  the  con- 
stricting efll'cts  of  tense  skin  and  f:\scia.  The  escape  of  ptomaines  and 
toxalbuniins  in  the  exudate,  whose  absorption  is  favored  by  the  extra- 
vascular  pressure  of  tension,  is  another  benefit.  Many  short  incisions 
through  skin  and  fascia,  thus,  — 'Z^ — ZZ — ,  will  relieve  tension  better 

than  one  long  incision. 

As  inflammation  is  almost  solely  a  vascular  process,  it  may  lie  proper 
to  starve  it,  as  it  were,  in  rare  instances,  by  pressure  upon,  or  ligature  of, 
the  main  vessel  of  the  part. 

Astringents  are  possibly  useful  at  the  very  outset,  when  the  primary 
vascular  dilatation  is  commencing,  but  are  better  employed  during  the 
terminal  stages  of  certain  inflanunutions  of  the  mucous  membranes  of 
the  mouth,  nose,  urotln'a,  conjunctiva,  etc. 

Certain  drugs  possess  a  limited  value.  Tims  purgatives  dejilete, 
excrete  ptomaines  and  toxalbuniins,  revulse,  and  are  intlicated  in  orchitis, 
gonorrhcea,  and  septic  peritonitis.  Diaphoretics  and  diuretics  do  to  a  less 
extent  what  jnirgatives  effect,  and  also  lower  tcnijicrature.  Remedies 
lowering  the  cardiac  frequency  and  force  are  beneticial  only  at  the  outset, 
wliile  later  digitalis,  (piinine,  and  alcoliol  are  rctjiiisite  to  sustain  the 
heart.  Auscultation  of  the  heart  to  ascertain  whether  the  first  sound  is 
normal  or  weakened  is  more  to  be  depended  upon  than  the  character  of 
the  pulse.  Opium  relieves  pain,"  prevents  exhaustion  from  loss  of  sleep, 
and  contracts  the  peripheral  -^'apillaries :  except  in  children  it  is  best 
given  hypoderniically.  Excessive  felirile  heat,  dangerous  at  any  age  to 
the  heart  and  nerve-centres,  but  especially  in  the  young  and  tlie  old,  often 
causing  in  the  former   convulsions,  should   l)e   moderated  by  cpiinine, 

'  See  author's  paper  in  Tmngaclinnit  of  Avxer.  Siirr/.  Axxncialinn,  vol.  i.  p.  185,  "  Have 
we  any  tlierapentic  means,  :ls  proven  by  experiment,  which  directly  afi'ect  the  local  pro- 
cesses of  inflammation?" 

^  Care  should  be  exercised  lest  two  evils  follow :  first,  checking  of  the  secretions  so 
essential  as  a  means  of  elimination,  and  the  induction  of  morphinism  when  the  case  re- 
quires prolonged  treatment. 


342  DIAGNOSIS  AND  TREATMENT  OF  INFLAMMATION. 

dia])horetic.s,  .sponging,  and  the  cautious  use  of  antijiyretics.  If  any 
constitutional  vice  l)e  detectable,  as  gout,  rheumatism,  or  syphilis, 
n])])ni|)i'iate  remedies  nuist  be  given.  When  nervous  symjttoms  are 
j)i'onounced  in  drinkers,  chloral  and  the  bromides  are  indicated  to  pre- 
vent delirium  tremens. 

CoNSTiTiTTiONAL  TREATMENT. — There  is  no  special  treatment  for 
inflammation.  If  the  bowels  are  confined,  give  a  laxative,  preferably 
calomel,  followed  by  a  saline,  when  from  over-eating,  sedentar}-  habits, 
or  drinlc  the  liver  acts  inefficiently,  not  because  mercury  has  any  specific 
action,  but  because  it  is  acceptable  to  the  irritable  stomach  so  often  pres- 
ent and  is  an  intestinal  antiseptic.  Under  such  circumstances  moderately 
restrict  food  and  drink,  l)ut  never  alter  a  patient's  habits  unnecessarily. 
In  all  cases  get  the  history  of  the  patient.  If  underfed,  feed  up ;  if  over- 
fed, restrict  the  diet.  If  alcohol  is  used,  ascertain  the  form  and  (|uantity, 
and  employ  the  minimum  recjuisite  to  keep  the  patient  from  running  the 
risks  of  the  total  withdrawal  of  stinudants;  a  gin-drinker  will  not  do 
well  on  chanii)ague,  nor  a  beer-consumer  on  M'hiskey.  In  malarial 
neighborhoods  quinine  is  usually  advisable.  In  the  young  and  vigorous 
less  food  than  usual,  and  that  of  an  easily  digestible  nature,  must  be  em- 
ployed at  the  outset,  but  the  feeble,  in  whom  an  asthenic  type  of  inflam- 
mation is  apt  to  prevail,  should  receive  from  the  beginning  as  large 
quantities  of  easily  digestible  food  as  can  be  assimilated. 

Chronic  Inflammation. 

The  pathological  processes  are  essentially  the  same  as  in  acute  inflam- 
mation, the  vessels  remaining  dilated  with  continuous  escape  of  leucocytes 
and  li<|U(>r  sanguinis,  which  stinudatc  growth  and  excessive  prolifcrati<tn 
of  fixed  connective  tissue,  and  jwssibly  other  cells.  The  caitscn  are  the 
same  as  for  the  acute  process,  but  they  act  more  slowly  and  with  less 
intensity.  Passive  congestions,  the  strumous,  rheumatic,  or  gouty  diath- 
esis, with  constitutional  syphilis,  often  serve  as  predisposing  causes. 
The  exciting  causes  are  often  so  trivial  as  to  be  overlooked,  but  second- 
ary causes  maintain  the  inflammation.  Thus  the  tension  from  synovial 
effusion  produced  by  the  use  of  a  joint  in  a  rheumatic  person  after  a  slight 
injury  may  keej)  uj)  trouble  for  years.  Unsuspected  latent  tubercular  foci 
may  give  trouble  only  after  over-exertion  or  a  slight  traumatism  has  so 
increased  their  vascularity  that  renewed  growth  and  continuous  extension 
occur. 

Symptoms. — The  redness,  if  present,  is  dusky ;  there  is  apt  to  l)e 
pigmcntatioii  from  the  constant  escape  of  red  blood-cells.  A  dull 
aching,  most  marked  at  night,  increased  l>y  pressure,  or  perhaps  tender- 
ness only,  is  complained  of,  rather  than  acute  pain.  While  slight  increase 
of  heat  may  be  noted,  often  there  is  no  local  rise  of  temperature.  Swell- 
ing is  always  well  marked  and  detectable  if  the  part  be  not  too  deeply 
seated.  Constitutional  symptoms,  as  fever,  are  sometimes  alisent,  espe- 
cially if  no  important  organ  is  involved,  but  the  patient  is  usually  out 
of  health,  and  may  present  evidences  of  syphilis,  rheumatism,  gout,  or 
tubercle.  The  possible  terminations  of  chronic  inflammation  are  resolu- 
tion, sujipuration,  or  ulceration,  chronic  induration  or  thickening,  casea- 
tion, and  calcification. 


ULCERATION  AND  ABSCESS.  343 

Treatment. — All  secoiulary  causes  of  irritati(in  must  he  removed,  the 
dilated  vessels  with  their  sluggish  current  promoting  constant  escape  of 
leucocytes,  and  the  formation  of  a  low  grade  of  interstitial  connective 
tissue — *.  e.  scar-tissue — must  be  stimulated  to  contraction.  The  nutrition 
of  the  tissues  should  be  ])rom(ited  by  the  access  of  arterial  blood  and  the 
free  return  of  the  venous  blood,  and  means  sliould  be  taken  to  promote 
the  absorption  of  intlammatory  exudates.  Sup[)orting  pressure  will 
reduce  the  size  of  the  vessels  and  induce  atrophy  of  the  poorly-organized 
exudate.  Massage  will  break  down  exudates,  force  the  cells  into  the  sur- 
rounding lvmj>h-spaces,  increase  the  arterial  afflux,  and  favor  the  venous 
efflux.  Aiteruatc  hot  and  cold  douches  are  also  valuable  vascular  stimu- 
lants. Counter-irritation  l)y  l>listers,  the  actual  cautery,  etc.  is  of  value 
if  employed  upon  tiie  contiguous  vascular  areas  above  or  below  the  part, 
but  can  only  jjro\'e  harmful  \vhen  applied  to  the  part  itself.  Improve- 
ment of  the  general  health  by  appropriate  remedies  and  attention  to  any 
goutv,  rheumatic,  tubercular,  or  syphilitic  taint  is  essential  to  success. 

Gener.\l  Considerations. — Ulceration  and  Abscess. 

These  processes  are  always  the  result  of  microbic  infection  interfering 
with  the  normal  processes  of  repair,  the  so-called  "  plastic  inflammation," 
which  results  from  the  injury  of  aseptic  tissues,  provided  their  vitality 
be  not  at  once  destroyed.  All  su|)purative  processes  are  essentially  de- 
structive, resulting  in  loss  of  tissue.  A\'hen  such  microbic  inflammation 
takes  place  upon  a  free  surfiicc,  as  a  cutaneous  or  mucous  membrane,  loss 
of  substance  occurs  by  molecular  destruction  of  tissue,  the  processes 
which  produce  this  being  called  "  ulceration,"  and  the  resultant  area  of 
inflamed  tissue  which  has  suffered  loss  of  substance  is  called  an  "  ulcer." 

All  ulcers  heal  by  the  organization  of  granulations  which  become 
covered  by  epithelium.  When  primary  iniion  fails  or  when  sloughing 
results  from  traumatism,  tlie  term  "ulcer"  is  aj)p]ied  to  any  granulating 
surface  left,  because  healing  takes  place  by  the  same  proces.ses.  Although 
the  pathology  of  inflammation  and  suppuration  will  receive  extended 
notice  elsewhere,  it  is  essential  here  to  describe  briefly  certain  portions 
.  of  these  ]iroces.ses,  that  the  reader  may  comprehend  what  follows. 

From  the  ))resence  of  microbes  at  the  outset,  or  because  of  their  sec- 
ondary implantation  at  the  focus  of  inflammation,  the  tis.sues  at  this  spot 
become  so  crowdcil  with  exudates  that  they  are  practically  replaced  by 
masses  of  young  cells,  anil  the  vessels  are  thrombosed,  so  that  a  return 
to  the  normal  state  is  impossible  unless  a  new  vascular  supply  enables  the 
cells  of  the  exudate  to  develop  into  a  permanent  tissue.  In  the  normal 
reparative  processes-  nutriment  from  the  surrounding  vascular  areas 
reaches  the  most  centrally  located  cells,  passing  from  cell  to  cell  or  be- 
tween them,  tile  cells  Ix'iug  held  in  contact  by  the  intercellular  material 
until  vascular  loops  interpenetrate  the  exudate. 

The  presence  of  microbes  changes  all  these  processes.  The  resultant 
peptonizing  ferments  or  the  ptomaVnes  cither  attack  the  vitality  of  the 
cells,  or,  by  disassociating  tiicm  t)y  dissdlving  the  intercellular  cement,  })ut 
tlicm  into  condition  to  undergo  fatty  degeneration,  to  die,  and  to  become 
suspended  in  a  fluid,  the  /itjuai-  puriK,  composed  of  exuded  serum,  lique- 
fied intercellular  cement,  and  exudate.     When  these  processes  are  very 


344  DIAGNOSIS  AND  TREATMENT  OF  ABSCESS. 

rapid  small  areas  of  tissue  beeonio  surrounded  by  others  so  tii<)roiii;hly 
infiltrated  with  cells  that  upon  their  st)lution  into  pus  these  conipara- 
ti\-ely  unaltered  fragments  are  seen  floating  as  shreds  in  the  ])us.  \\'hen 
this  occurs  upon  a  free  surface  a  variety  of  sloughing  ulcer  results. 
AVhile  many  forms  of  microlx's  have  at  times  proved  to  he  j)yogenic, 
the  most  common  varieties  found  in  acute  abscesses  are  the  ytiijiliiilo- 
coccus  pi/of/ciici  aureus  and  a/bus.  The  fact  that  these  germs  tend  to 
aggregate  into  clusters  (hence  their  name)  would  seem  to  exjjlain  the 
circumscribed  chai'acter  of  the  suppurations  they  initiate.  A  marked 
difference  is  usually  noticeable  in  ]iurulent  conditions  induced  by  strep- 
tococci. These  germs  rapidly  become  diffused  through  the  tissues  by 
way  of  the  lymphatics,  and  are  therefore  apt  to  originate  diffused  sup- 
puration. 

That  microbes  are  the  cause  of  suppuration  would  seem  to  be  contra- 
dicted by  the  occasional  failure  to  find  them  in  cold  abscesses,  but  the 
explanation  of  the  ajjparent  exception  is  twofold  :  either  that  they  were 
present  earlier,  but  died  from  lack  of  pabulum  or  self-poisoned  bv  their 
own  excreta,  or  that  in  the  given  instance  the  tubercle  l)aeillns  acted  as 
a  pyogenic  organism;  which  is  unciuestionably,  although  rarely,  true. 
Again,  however  closely  it  may  resemble  pus,  the  fluid  contained  in  many 
cold  abscesses  is  not  pus,  but  liquefied  caseated  tubercle,  no  pus-cells 
being  discernible.  Local  sujipuration  can  be  promptly  and  certaiidy 
produced  by  the  inoculation  of  ordinary  pus-germs,  as  liy  rubl)ing  pure 
cultures  into  the  intact  skin.  The  fluid  resulting  from  the  injection  of 
aseptic  chemical  substances,  such  as  turpentine,  croton  oil,  etc.,  is  puruloid, 
but  is  not  pus.  It  is  merely  a  fibrinous  exudate  containing  numerous 
cells ;  is  only  seen  when  exceptionally  favorable  laboi'atory  conditions 
are  secured  ;  shows  no  tendency  to  spontaneous  evacuation,  as  true  pus 
does,  because  the  solvent  action  of  the  peptonizing  liacterial  ferment  is 
absent,  which  also  prevents  the  coagulation  of  new  exudate  ;  and  finally, 
is  never  found  clinically.  Again,  the  injection  of  a  jitomaine  into  the 
tissues  merely  reproduces  the  conditions  which  would  be  furnished  if 
bacteria  were  present. 

Predisposing-  Causes. — Abscess  being  a  result  either  of  primary  or 
of  secomlary  microbic  inflammation,  those  ccmditions  which  experience  has 
.shown  to  predispose  to  this  variety  of  inflammation  nnist  favor  pus-j)ro- 
duction.  Local  conditions  which  lower  the  vitality  of  the  tissues,  and 
general  impairment  of  nutrition,  however  effected,  favor  microbic  inflam- 
mation. Temporary  slowing  of  the  circulation  from  accidental  causes, 
especially  when  aided  by  anatomical  conditions,  favors  localization  of 
microbes.  Thus  a  trivial  contusion  of  the  medulla  of  bone,  rupturing  a 
few  vessels  in  which  thrombi  form,  produces  a  collateral  hyperemia  which 
produces  a  slowing  of  the  circulation,  so  that  mechanically — being  heavier 
than  the  blood-cells — the  germs  accumulate.  The  tortuosity  of  the  medul- 
lary vessels,  and  in  consequence  the  sluggish  current  flowing  through  them, 
favor  microbic  implantation,  so  that  exjiosurc  to  cold,  driving  the  blood 
from  the  surface,  may  cause  such  additional  dilatation  of  the  vessels  as 
to  determine  an  accumulation  of  germs  if  they  have  gained  access  to  the 
circulation  by  any  distant  infection-atrium. 

General  Symptoms  of  Abscess. — Pus-formation  is  so  often  pre- 
ceded by  a  chill  or  rigor  that  when  this  occurs  during  an  attack  of  local- 


ACUTE  ABSCESS.  345 

ized  inflammatioii  it  is  too  commonly  vicwi'il  as  a  oonelnsive  symptom,  es- 
pecially if  the  fever  which  results  is  followed  by  a  second  chill.  This  idea 
is  erroneous,  as  in  some  individuals,  especially  when  certain  parts  or  organs 
are  involved,  the  chill  may  he  only  indicative  of  the  thorough  establish- 
ment of  the  intlanimatory  process  or  the  sudden  involvement  of  a  new 
area  :  again,  all  malarial  poisoning  nuist  be  excluded.  Fever  will  be 
present  in  varying  degrees,  witli  its  concurrent  anorexia,  coated  tongue, 
dry  skin,  confined  bowels,  and  scanty  urine.  In  some  individuals  de- 
lirium may  be  present ;  but  all  these  symptoms,  it  must  be  remarked, 
are  not  those  of  abscess  specially,  but  of  the  inflammatory  process  which 
is  terminating  in  sujtpuration. 

As  the  thoroughly  infiltrated  focus  dissolves  into  pus  the  peripheral 
area,  just  about  to  be  converted  into  granulation  tissue  by  the  ingrowth 
of  capillary  loops,  is  attacked  by  the  ingrowing  germs  and  tlieir  solvent 
])roducts,  and  breaks  down  into  pus,  thus  enlarging  the  abscess-area. 
This  futile  attempt  at  the  formation  of  gramdations  usually  goes  on 
until  nature  or  art  evacuates  the  abscess,  when,  the  tension  being 
relieved,  the  excessive  vascularity  disai)pears,  the  perijihcral  layer  of 
granulations  becomes  perfected,  the  cavit}'  collapses,  the  apposed  sur- 
faces fuse,  and,  epidermis  forming  over  the  skin-orifice,  cicatrization  is 
completed,  the  granulation  tissue  becoming  converted  into  connective 
tissue  ;  i.  e.  a  subcutaneous  contracting  xcar  forms. 

When  the  jn-ocesses  are  slowcn-,  or  from  any  cause  the  ])vogenic  organ- 
isms lose  tiieir  virulence,  the  peripheral  layer  of  intiltratctl  tissue  becomes 
converted  into  granulation  tissue,  but  from  the  non-evacuation  of  the 
pus  is  prevented  from  fulfilling  its  normal  function — viz.  conversion 
into  fidly-formed  but  low-grade  connective  tissue  ;  this  process  stops 
halfway,  the  deeper  layers  undergoing  this  change,  while  the  superficial 
remain  here  and  tliere  as  scattered,  ill-formed  granulations :  this  mem- 
brane-like structure  is  the  miscalled  pyogenic  membrane. 

Acute  Abscess. 

The  causation,  pathology,  and  mcth(^d  of  healing  must  be  sought  in 
the  section  on  Inflammation. 

Symptoms. — During  an  acute  inflammation  the  process  becomes 
more  localized  at  one  point.  Throbbing  ]iain  is  felt,  and  a  chill  often 
occurs  when  pus  forms.  If  superficial,  the  inflammatory  redness  and 
swelling  become  more  circumscribed  ;  palpation  discovers  central  soften- 
ing and  fluctuation  :  this  spot  becomes  more  ]5ronnnent — /.  c.  ])ointing 
takes  place.  The  skin,  becoming  j)urplish,  glazed,  and  thinned,  gives 
way,  either  after  the-  sejiaration  of  a  slough  or  by  ulceration  following 
the  formation  and  rupture  of  a  bleb  of  cuticle.  A  deep-seated  absces.s 
is  shown  by  oedema,  mottling  of  the  skin,  tenderness,  and  localized 
induration,  or  a  sense  of  resistance  of  the  deeper  parts,  with  obscure 
fluctuation  ;  fever,  and  probably  rigors,  having  preceded  these  symptoms. 
When  in  doubt  the  grooved  needle  nnist  be  emjiloyed. 

Treatment. — Up  to  the  time  of  incision  or  rupture  warm  jioultices 
will  hasten  the  process  and  limit  its  extent,  but  when  about  to  be  spon- 
taneously evacuated  moist  antiseptic  dressings  must  be  substituted.  Pus 
should  always  be  early  evacuated  by  incisions  made  at  the  mo.st  depend- 


346  BIAGNOSIS  AND  TREATMENT  OF  ULCERS. 

ent  part  to  facilitate  drainage  if  no  important  s^tructnrcs  are  in  the  way. 
Snch  incisions  must  be  free,  and  should  l)e  followed  l)y  the  introduction 
of  drainage-tubes.  Sometimes  counter-openings  are  advisable.  Pus  ought 
to  be  allowed  to  flow  away,  because  pressure  will  rupture  granulations, 
the  only  barrier  against  absorption  of  noxious  })roduets.  Subsequently, 
antiseptic  dressings  must  be  used— never  a  poultice.  Pus  is  always  de- 
structive, causing  absorption  of  the  tissues  as  it  pursues  the  line  of  least 
resistance,  and  may  open  into  joints,  nnicous  canals,  etc. ;  hence,  when 
in  the  perineum,  near  the  peritoneum,  in  a  tendon-sheath,  beneath  tense 
fascia,  or  compressing  a  canal,  as  the  trachea  or  urethra,  especially 
prompt  intervention  is  demanded.  In  exposed  parts  the  sear  of  an 
incision  is  less  unsightly  than  that  following  Nature's  efforts.  When 
pus  deeply  underlies  important  vessels  or  nerves  a  small  incision  through 
the  skin  and  fascia  should  be  made,  the  tissues  bored  through  with  a 
grooved  director  until  pus  is  reached,  along  this  instrument  a  pair  of 
dressing-forceps  be  introduced,  closed,  and  withdrawn  partly  opened,  thus 
lacerating  the  structures  without  risk  to  arteries  or  nerves ;  a  drainage- 
tube  can  then  be  inserted.  This  is  "  Hilton's  method."  Rarely,  from 
loss  of  support,  severe  venous  hemorrhage  follows  ojjening  an  abscess, 
or  later  a  large  vessel — vein  or  artery — ulcerates. 

[So-called  chronic  or  cold  abscess,  being  really  a  tubercular  process, 
will  be  treated  of  in  another  part  of  this  work. 

Ulcers. 

As  already  stated,  an  ulcer  is  a  solution  of  continuity,  situated  upon 
the  skin  or  a  mucous  membrane,  jtroduced  by  molecular  loss  of  sub- 
stance, sometimes  increased  by  sloughing,  the  result  of  microbic  in- 
flammation :  any  granulating  surface  left  after  accident  or  operation  is 
also  called  an  "  ulcer." 

Although  ulcers  may  be  described  as  belonging  to  one  or  other  of 
certain  classes,  accidental  conditions  may  cause  them  to  change  their 
characteristics.  Ulcers  are  divided  into  those  where  the  characteristic 
appearances  are  due  to  local  conditions,  and  those  resulting  from  specific 
or  constitutional  causes.  In  this  section  we  arc  concerned  with  the  first 
class  only. 

Simple  Healthy  or  Healing  Ulcer. — As  every  ulcer  must 
attain  this  condition  as  it  cicatrizes,  the  appearances  of  this  form  of 
ulcer  must  be  carefully  studied,  all  non-specific  ulcers  being  mere  varia- 
tions from  this  type,  the  result  of  ol)staeles  to  Nature's  attempt  to  heal 
by  the  organization  of  granulations  and  their  covering  over  by  epi- 
dermis. 

The  margins  are  smooth,  shelving  down  to  a  level  base,  which  is  cov- 
ered by  healthy  granulations  moistened  -with  a  small  quantity  of  creamy, 
inodorous  pus.  The  surroun<liug  tissues  are  healthy,  and  not  inflamed. 
The  edges  of  the  ulcer  are  not  tender,  and  merge  gradually  with  the 
granulations  by  a  bluish-white  film,  opacpie  and  whiter  on  the  skin  side, 
bluish  and  translucent  at  the  j)oint  of  junction  with  the  granulations. 
These  appearances  are  due  to  the  advancing  epithelial  covering,  consist- 
ing of  many  layers  resting  upon  slightly  vascular,  newly-organized 
granulation  tissue  where  opaque  and   white,  allowing  the  tint  of  the 


ULCERS.  347 

more  vascular,  iinperfeotly-dcvcloped  siramilation  tissue  to  show  through 
the  thimier  kiyers  of  epitlieliuin  wliere  hhiisli. 

Treatment. — Protection  from  irritants  and  rest  for  the  part  are  all 
that  are  usually  requisite  unless  the  surface  be  very  extensive,  when  skin- 
grafting,  preferably  by  Thiersch's  method,  may  become  requisite. 

Fungous  Ulcei;. — Let  anything  interfere  with  the  return  circula- 
tion from  a  simple  ulcer,  as  position,  or  excessive  formation  of  scar-tissue 
in  and  around  the  margins  of  the  ulcer,  and  the  granulations  will 
become  congested,  overgrown,  ill-formed,  projecting  above  the  healthy 
margins,  bleeding  upon  the  slightest  touch,  and  secreting  an  abundant 
thin,  purulent,  possibly  blood-stained,  discharge. 

Treatment. — Remove  the  cause,  by  position  favor  the  return  of 
venous  blood,  emjiloy  agents  which  will  constringe  the  vessels  of  the 
granulations,  and  give  mechanical  suj>port  to  the  circulation — /.  e.  pres- 
sure. Solutions  of  sulphate  of  cojipcr  (gr.  j-x  to  fsj),  sulphate  of  zinc 
or  nitrate  of  silver  in  the  same  strength,  sterilized  oxide-of-zinc  oint^ 
ment,  with  occasional  use  of  the  solid  stick  of  nitrate  of  silver,  and 
sometimes  compression  effected  by  a  roller  bandage,  usually  suffice. 

The  CEdematous  Ulcer. — Employ  wet  dressings  or  prolonged 
])oulticing,  especially  with  a  feeble  venous  circulation  in  the  part,  and, 
although  the  margins  of  a  previously  healing  ulcer  may  remain  fairly 
healthy,  the  granulations  will  become  swollen,  flabby,  pale,  semi-translu- 
cent, and  friable  from  aKlema,  and  will  extide  much  watery  pus. 

Treatment. — Here  more  blood,  and  blood  circulating  at  a  proper 
iiite,  is  demanded  ;  hence  stinudant  ajjplications,  as  grs.  v-x  of  chloral 
to  .y  of  water,  resin  ointment,  l>alsam  of  Peru,  or  some  astringent,  and 
meclianical  support,  are  indicated. 

The  Inflajimatory  Ulcek. — Let  certain  individuals  indulge  freely 
in  alcohol,  especially  if  previously  ill-nourished  and  improperly  fed  dur- 
ing their  drinking-bout,  and  a  traumatism  which  would  in  others,  or  even 
in  them  under  more  favorable  circumstances,  produce  an  ordinary  ulcer, 
often  will  residt  in  a  ra]Mdly-enlarging  ulcer  of  irregular  form,  having 
sharp-cut  or  ragged  margins,  the  Itase  formed  of  the  red,  inflamed  tissues 
freely  secreting  a  sero-sanguinolent  discharge,  which  often  contains 
shreds  of  tissue.  If  the  inflanmiation  is  hyperacute,  the  base  of  the 
ulcer  may  be  covered  with  yellowish  sloughs.  The  circumjacent  skin 
is  inflamed  and  cedematous. 

Inflamed  Ulcer. — When  a  ])rcviously  healthy  ulcer  is  irritated, 
neglected,  and  dirty,  especially  in  drinkers,  inflanunation  may  attack  the 
granulations,  which  become  red  and  swollen,  and  slough ;  the  margins 
break  down,  the  ulcer  spreads,  and  the  surrounding  tissues  present  the 
ordinary  phenomena 'of  inflammation. 

Treatment. — Removal  of  all  local  irritation,  elevation  of  the  parts, 
warm,  moist,  unirritating  antiseptic  lotions,  as  of  boric  acid,  or,  better, 
when  feasil)le,  the  continuous  warm  antiseptic  bath,  are  indicated. 
Drinking  should  be  stopped,  more  food  and  of  a  better  quality  must  be 
provided,  and  the  eliminative  organs  stinudated.  This  combined  local 
and  general  treatment  will  usually  soon  convert  either  the  inflanunatory 
or  the  inflamed  ulcer  into  a  simple  one. 

The  Sloughing  Ulcer,  except  when  this  term  is  applied  to  the 
worst  cases  of  the  varieties  just  described,  is  rarely  seen  except  in  con- 


348  DIAGNOSIS  AND  TREATMENT  OF  ULCERS. 

nection  witli  venereal  disease  in  those  broken-down  by  ak'ohol  and 
sexual  excesses.  In  such  patients  destruction  of  parts  ])r()grcsses  with 
great  rapidity.  The  cellular  tissue  is  more  extensively  dcstmyed  than 
the  skin  ;  hence  the  edges  of  the  ulcer  are  undermined  and  inverted, 
and  of  a  dusky-red  hue,  the  base  being  covered  with  gray  (ir  black 
sloughs.  Tliere  is  great  pain,  and  severe  constitutional  disturbance  is 
the  rule. 

Treatment. — This  docs  not  differ  from  that  of  the  inflamed  ulcer, 
except  that  anodynes  will  be  required  to  relieve  pain,  and,  as  svpliilis  is 
often  present,  mercury  must  be  used  with  a  sparing  hand  or  be  entirely 
withheld.     Tonics,  good  food,  and  stinndants  will  often  be  requisite. 

The  Phagedenic  Ulcer  is  believed  to  result  from  the  multipli- 
cation of  a  specific  micro-organism  in  the  tissues  of  those  broken  down 
by  intemperance,  bad  food,  etc.,  and  is  usually  of  venereal  (chancroidal) 
origin.  The  surrounding  skin  is  of  a  dusky-red  or  ])urplish  hue.  The 
margins  of  the  ulcer  are  ragged  and  uudcrmiiUMl,  tiie  l)ase  is  covered 
with  bloody  discharge  and  sloughs,  and  when  tiiis  last  condition  is  pro- 
nounced what  is  termed  a  "  sloughing  phagedena  "  results.  The  tissues 
melt  away  with  astounding  rapidity,  the  external  genitals  of  the  male 
or  female  sometimes  being  totally  removed.  Great  pain  and  high  fever 
are  the  rule. 

Treatment. — As  infection  by  a  virulent  organism  is  the  cause,  thor- 
ough destruction  of  the  surface  and  margins  of  the  ulcer,  with  some  of 
the  adjacent  tissues,  must  be  effected  by  strong  nitric  acid,  bromine,  or 
the  actual  cautery.  In  the  milder  forms  disinfection  with  a  1  :  1000 
corrosive-sublimate  solution,  followed  by  the  free  use  of  iodoform,  may 
suffice.  The  continuous  warm  antiseptic  bath  may  supersede  or  supple- 
ment other  methods.  Opium,  tonics,  stimulants,  and  good  food  are 
imperatively  demantled,  with  improvement  of  the  patient's  hygienic 
surroundings  if  these  be  poor. 

Indolent  or  Chronic  Ulcer. — Let  any  granulating  surface  have 
its  healing  processes  repeatedly  interfered  with  bj'  mechanical  or  other 
irritatiiin,  and,  while  the  formation  of  epidermis  is  prevented,  the  em- 
bryonic tissue  forming  the  margins  and  base  will  develop  into  dense 
filn'ous  tissue,  fixing  them  to  the  subjacent  fascia,  periosteum,  or  lione. 
This  is  aided  by  a  weak  venous  circulation,  favoring  congestion,  which 
condition  of  the  circulation  may  result  either  from  a  feeble  heart,  vari- 
cosity of  the  veins,  the  dependent  position,  or  all  combined.  In  addi- 
tion, the  contracting  cicatricial  tissue  cuts  oft'  much  of  the  arterial  supply, 
preventing  the  formation  of  healthy  granulations.  Healing  is  also  seri- 
ously interfered  with  Ity  cicatricial  fixation  of  the  margins  and  base  of 
the  ulcer,  for,  as  will  be  explained  (see  p.  368),  much  of  the  healing  of 
any  granulating  surface  depends  upon  diminution  of  its  superficial  area 
by  contraction  of  the  deeper  layers  of  granulation  tissue,  which  fixation 
of  the  base  to  the  deeper  structures  absolutely  prevents.  These  points 
must  be  kept  in  view  as  governing  thei'apeutics. 

Symptoms. — The  lower  third  of  the  leg  is  the  favorite  position,  and 
the  poorer  classes  the  victims.  The  edges  are  smooth,  rounded,  much 
elevated,  insensitive,  while  the  circumjacent  skin  is  bronzed  or  purplish  : 
eczema  is  quite  common.  The  base  has  few  if  any  granulations,  and 
these  are  scattered,  pale,  and  flabby,  and  covered  with  an  oftentimes  very 


ULCERS.  .349 

offensive  thin,  piiruloid,  or  sanious  discharg'e.  Usually  hut  little  pain  is 
experienced.  When  left  untreated  they  last  for  ten,  twenty,  thirty,  or 
forty  years.  Certain  of  these  ulcers,  if  subjected  to  constant  irritation, 
undergo  an  epithelioniatous  change,  and  are  then  known  as  "  jNIarjolin's 
ulcer.'' 

Treatment. — This  must  depend  ujjon  the  conditions.  If  access  of 
arterial  lilood  is  prevented  by  the  cicatricial  margins,  radiating  incisions 
through  these  may  be  made,  a  fly  blister  may  l)e  applied  covering  base 
and  margins,  tincture  of  iodine  may  be  similarly  employed,  or  ati'ophy  be 
induced  by  the  pressure  of  an  elastic  l3an<lage  or  adhesive-plaster  strap- 
ping. If  venous  return  is  markedly  interfered  with,  as  is  so  common,  rest 
in  bed,  if  possible,  must  be  employed  or  support  afforded  the  veins  by 
bandaging  or  an  elastic  stocking.  In  a  few  instances,  where  further 
contraction  of  the  base  is  rendered  impossible  by  the  adherent  margins, 
interrupted  or  comjjletely  encircling  incisions,  placed  aliout  one  inch 
from  the  margins,  will  ])rove  useful,  the  free  bleeding  being  arrested  by 
antiseptic  packing.  Again,  the  base  and  margins  may  be  curetted,  free 
disinfection  effected  by  chloride  of  zinc  in  solution,  peroxide  of  hydrogen, 
etc.,  when  subsequent  antiseptic  dressings  and  the  recumbent  posture  will 
often  effect  a  cure.  Where  the  power  of  the  margins  to  reproduce  epi- 
thelium is  impaired,  and  the  jihysical  conditions  are  unfavorable  for 
diminution  in  area  by  contraction,  skin-grafting  is  indicated.  Araputa- 
tum  is  occasionally,  but  rarely,  demanded. 

When  eczema  of  the  skin  surrounding  any  variety  of  ulcer  is 
marked,  the  term  "eczematous  ulcer"  has  been  applied.  If  varicose 
veins  exist,  the  ulcer  is  often  called  a  "  varicose  ulcer."  Except  for 
the  fact  that  in  the  first  case  tlic  condition  of  the  skin  may  call  for 
somewhat  different  dressings,  and  in  the  second  that  interference  with 
venous  return  prevents  that  proper  condition  of  the  circulation  in  the 
parts  which  is  essential  to  the  formation  of  healthy  granulations, 
these  distinctions  are  worse  than  useless  as  implying  some  specific 
cause. 

In  certain  women — usually  over  forty  years  of  age — a  form  of  ulcer 
is  seen  called  the  "  irritable  or  painful."  It  is  connnonly  situated  above 
and  near  to  the  ankle — is  small,  superficial,  and  usually  markedly  con- 
gested. There  can  be  no  question  as  to  the  involvement  of  some  nerve- 
filament  standing  in  a  causative  relation.  This  is  shown  by  treatment. 
In  a  few  instances  examining  the  surface  carefully  with  the  point  of  a 
probe  will  demonstrate  some  sjiccially  tender  point. 

Treatment. — Rest  in  bed,  elevation  of  the  parts,  simple,  non-irritat- 
ing antiseptic  dressings,  passing  a  tenott)me  liencath  the  margin  of  the 
ulcer  at  any  spot  where -by  point-pain  the  involvement  of  a  nerve-twig  is 
demonstrable,  or,  where  this  cannot  be  detected,  the  administi-ation  of 
a  grain  of  opium  three  or  four  times  daily,  will  usually  effect  a  cure  :  this 
latter  drug  is  really  curative,  as  under  its  use  tlic  congestion  disappears, 
because  irritation  of  a  sensory  nerve  will  produce  congestion  in  tlie  area 
supplied  by  that  nerve. 

Descriptions  of  syphilitic,  gouty,  tubercular,  lupous,  scorbutic,  and 
carcinomatous  and  rodent  ulcers — which  last  are  really  superficial  epi- 
thelioniatous ulcers — must  be  sought  for  in  the  proper  sections  of  this 
work. 


350  DIAGNOSIS  AND  TREATMENT  OF  FURUNCLE. 

PUBUNCLE. 

Furuncle,  or  boil,  is  a  localized,  deep-seated  inflammation  of  the  skin, 
producing  one  or  many  circumscribed,  firm,  acuminated,  painful  swell- 
ings, in  which  central  sloughing  and  .suppuration  usually  occur.  Occur- 
ring in  numbers  and  successive  crops,  the  term  "  furunculosis  "  is  applied 
to  the  condition. 

Symptoms. — First,  a  small,  reddened,  ill-defined,  tender  point 
appears  in  the  true  skin.  This  increases  in  size,  becomes  elevated, 
pointed,  is  densely  hard,  very  painful,  and  dusky  red.  In  from  a 
week  to  ten  days  central  sujipuration  occurs,  the  little  jiustule  ruptures, 
revealing  a  yellowish  central  slongli,  at  the  periphery  of  which  pus  can 
be  expressed.  In  a  day  or  two  the  slough  separates  with  rather  free 
suppuration,  leaving  a  little  crater-like  cavity.  The  pain  and  snjipura- 
tion  now  jiromptly  subside  and  cicatrization  occurs,  leaving  a  purplish 
indurated  mass  for  some  little  time.  Sometimes  the  inflannnation  stops 
shoii  of  suppuration,  a  "  blind  boil "  resulting. 

Sites. — Any  portion  of  the  cutaneous  surface,  but  preferably  the  face, 
neck,  and  contiguous  parts,  the  back,  axillre,  buttocks,  perineum,  scrotum, 
and  extremities. 

Causation. — Mental  overwork,  excessive  bodily  fatigue,  irregular  hab- 
its, improper  food,  and  all  causes  which  depress  vitality  seem  to  predi.s- 
pose  to  boils.  Diabetics  and  ansemic  patients,  and  those  suffering  from 
urffimia  or  from  sepsis,  are  pi'one  to  them.  Occasionally  persons  appar- 
ently in  vigorous  health  will  have  frequently-recurring  boils.  It  is 
alleged  that  the  pseudo-epidemics  of  boils  which  sometimes  prevail  dur- 
ing the  spring  and  autumn  are  due  to  atmospheric  influences :  this  can 
only  lie  true  because  rapid  variations  in  temperature  and  atmospheric 
pressure  produce  changes  in  the  cutaneous  circulation. 

Diagnosis. — The  boil  can  hardly  be  confounded  with  anything  but  a 
carbuncle,  which  is  larger,  flattened,  has  many  points  of  suppuration, 
is  single,  and  is  painful,  but  not  tender. 

Treatment. — Success  is  often  not  easy  to  attain.  Removal  of  the 
cause  when  possible  to  ascertain,  fresh  air  and  moderate  exercise,  atten- 
tion to  the  bowels  and  digestion,  carefully-regulated  but  varied  diet, 
tonics,  quinine,  arsenic  and  iron,  sulphide  of  calcium,  sulphite  or  hypo- 
sulphite of  calcium,  etc.,  have  all  proved  useful  at  times. 

Ahorfive  Treatment. — When  a  hair  is  in  the  centre  of  the  boil  its 
evulsion  will  sometimes  arrest  the  process.  I  am  doubtful  whether  pen- 
etration of  the  ajiex  with  a  hot  needle  or  the  use  of  carbolic  acid  is 
advisal)le,  although  these  procedures  have  high  authority  upon  their 
side. 

Local  Treatment. — As  the  penetration  of  germs,  notably  the  stajiliylo- 
coccus  pyogenes  aureus,  into  the  hair-  or  sweat-follicles,  and  thence  into 
the  epidermis,  causes  boils,  cleansing  of  the  parts  and  arrangement  of  the 
clothing,  so  as  to  prevent  friction  aiding  penetration  of  micro-organisms, 
are  important.  Thus,  after  cleansing,  a  10  per  cent,  salicylic-acid  oint- 
ment may  be  gently  rubbed  into  the  skin,  or  ichthyol  in  full  strength  or 
diluted. 

When  .suppuration  has  occurred  or  is  threatening,  a  moist,  weak  germ- 
icidal dressing  covered  with  oil-silk  or  rubber  tissue  is  indicated.     Anti- 


PAPMXYCHIA.  351 

sepsis  and  asepsis  should  be  maintained,  as  more  than  one  fatal  case  of 
pyaemia  or  septico-pyiemia  has  had  its  origin  in  a  boil. 

Paronychia. 

Felon,  or  paronychia,  is  an  infective  cellulitis  attacking  the  soft  parts 
of  the  fingers,  and  more  rarely  those  of  the  toes.  This  may  involve 
the  sheaths  of  the  tendons  or  the  periosteum.  The  anatomical  disposi- 
tion of  the  structures  forming  the  pulp  of  the  fingers  will  ex])lain  cer- 
tain differences  in  the  course  pursued  by  a  whitlow  of  a  distal  as  com- 
jjared  with  one  of  a  proximal  phalanx.  The  distal  phalanges  possess  no 
separate  ])eriostenm,  the  vessels  supplying  these  hones  ramifying  in  the 
dense  cellulo-adipose  tissue  forming  thi'  finger-pulps,  which  tissue  is  con- 
tinuous with  the  skin  and  bone  through  the  medium  of  numerous  con- 
necting fibrous  bands.  Hence  a  destructive  infianuuatiou,  if  deep  seated, 
especially  if  it  lead  to  sloughing  of  the  pulp,  almost  necessarily  leads  to 
necrosis  of  the  underlying  jjortion  of  the  phalanx.  As  the  first  and  second 
phalanges  possess  a  distinct  periosteum,  abscesses  of  the  soft  parts  cover- 
ing them,  or  a  suppurative  teno-synovitis,  may  occur  without  death  of  the 
bone,  although  this  often  <iccurs  in  neglected  cases.  Su[)purative  teno- 
synovitis in  this  locality  may,  however,  extend  upward,  producing 
palmar  abscess,  or  even,  when  localized,  sloughing  of  the  tendon.  Par- 
onychia is  alleged  sometimes  to  occur  as  an  epidemic,  but  it  more 
usually  results  froua  infection  by  pyogenic  organisms  of  some  trivial 
puncture,  cut,  or  contusion,  in  the  last  event  the  germs  gaining  access 
to  the  circulation  by  some  distant  infeetion-atrium  and  liecoming  local- 
ized at  the  point  of  injury — /.  c.  a  locus  ininoris  resistcntiaj. 

Symptoms. — There  are  two  distinct  varieties — viz.  a  superficial  and 
a  deep.  The  superficial  may  attack  one  or  several  fingers  in  turn,  and 
often  affects  the  tissues  around  or  under  the  nail.  When  slight  the  dis- 
ease may  promptly  subside,  but  if  more  severe,  serous  or  purulent  col- 
lections take  place  beneath  the  epidermis,  whicli,  if  removed,  leaves  a 
raw,  reddened,  or  ulcerated  derm,  the  cicatrix  remaining  for  some  time 
reddened  and  tender.  A\'hen  the  inflammation  runs  high  suppuration  is 
free,  and  fungous  granulations  are  apt  to  form  beneath  or  around  the 
nail,  which  after  weeks,  or  perhaps  months,  exfoliates  in  whole  or  in 
part. 

Treatm.ent. — Rest,  elevation,  and  moist,  non-irritating  antiseptic 
dressings  are  all  that  are  requisite  for  the  milder  cases.  For  the  more 
severe  type  antiseptic  gauze  or  cotton  poultices,'  and  prompt  aseptic 
incision  when  pus  forms,  are  indicated.  Tonics  and  good  food  are 
recpiired  if  the  patient  be  in  feeble  health.  If  the  nail  mechanically 
maintains  the  irritation,  it  must  he  removed  partially  or  entirely,  the 
exuberant  granularions  lie  destroyed  by  the  curette  or  powdered  nitrate 
of  lead,  and  asepsis  be  secured  and  maintained  by  proper  dressings. 

The  deep  whitlow,  while  it  may  start  in  the  dorsum  or  some  other 
surface  of  any  jihalanx  if  an  injury  be  there  situated,  most  commonly 
originates  on  the  palmar  surface  of  the  finger-tip.     Deep-seated  inflam- 

'  By  this  term  is  meant  the  maintenance  nf  warmtli  and  moisture  by  covering  tlie 
wetted  cotton  or  gauze  with  a  substance  impervious  to  moisture,  and  which  retains  tlie 
heat,  as  oiled  silk,  waxed  paper,  or  rubber  tissue. 


352  DIAGNOSIS  AND   TREATMENT  OF  DRACONTIASIS. 

niations,  shown  by  redness,  tendei-ness,  swellin<j,  tension,  and  tlin)l)l)ing 
pain,  manifest  themselves  in  from  a  few  lionrs  to  several  days  after  the 
injury,  with  inereasing  fever.  All  the  ioeal  conditions  are  agfi;ravated 
by  the  dependent  position.  Suppuration  is  the  rule,  resolution  the 
exception,  pus  usually  formincr  early,  but,  owing  to  the  density  of  the 
tissues,  fluetuation  is  difHt'ult  to  detect.  Care  must  be  exercised  not  to 
overlook  the  more  deep-seated  pus  because  of  the  occasional  formation 
of  a  superficial  collection  of  matter.  Gangrene,  although  i-are,  has  been 
observed.  Abortive  treatment  by  nitrate  of  silver,  iodine  tincture,  etc. 
is  so  rarely  successful  that  it  cannot  be  recommended.  Hot  fomen- 
tation.s,  followed  by  warm  antiseptic  poultices,  may  be  tried  for  about 
forty-eight  hours,  wlicn,  if  decided  retrogression  of  the  symptoms  does 
not  occur,  free  aseptic  incision  must  be  resorted  to,  esj)ecially  when  the 
last  phalanx  is  involved,  when  an  early  cut  reaching  to  the  bone  often 
atibrds  the  only  chance  of  preventing  necrosis.  If  the  tissues  over  the 
first  or  second  phalanx  be  involved,  the  early  incision  had  better  open 
the  tendon-sheath,  because  probably  at  this  time  only  a  suppurative  teno- 
synovitis exists,  but  later  lateral  or  other  incisions  may  become  requisite, 
which  should  extend  down  to  the  bone.  Sjjontaneous  separation  of  the 
necrosed  distal  ])halanx  near  the  epiphyseal  line  will  often  take  place, 
leaving  a  deformed  but  useful  tinger-tip.  Death  of  a  first  or  second 
phalanx  usually  indicates  amputation,  although  sometimes  excision  of 
the  necrosed  portions  may  leave  a  fairly  useful  finger. 

Dbacontiasis. 

This  is  due  to  the  development  of  a  nematode  worm  (Filaria  or  Dra- 
cunculus  Medinensis,  Guinea-worm)  in  the  tissues,  resulting  in  the  for- 
mation of  a  subcutaneous  tumor  just  before  the  exit  of  the  worm.  The 
larv;e  of  the  parasite  gain  access  to  the  system  by  the  drinking-water. 
In  Guinea,  the  Gold  Coast,  Arabia,  Upper  Egypt,  Nubia,  Abyssinia, 
Hindostan,  and  a  few  other  localities  it  is  endemic. 

Symptoms. — Until  the  worm  is  nearly  mature  there  are  no  symptoms, 
but  a  small  coiled-up  mass  can  be  felt  subcutaneously.  In  mild  cases  a 
small,  circumscribed  tumor  forms,  accompanied  by  itching  and  tension. 
The  tumor  may  not  form  exactly  where  the  worm  was  first  detected. 
From  scratching  or  other  cause  the  tumor  ruptures,  serum  escapes,  and 
the  white  extremity  of  the  worm  can  be  seen  in  the  cavity  left.  If  ])ro])- 
erly  treated,  the  worm,  which  soon  protrudes,  should  be  gotten  rid  of 
in  from  three  to  ten  clays.  Some  patients  suifer  from  violent,  painful 
infiammation  along  the  entii'e  worm-track,  resulting  in  abscess  with 
marked  ct)nstitutional  symptoms.  Sometimes  in  these  cases  the  worm 
perishes,  softens,  and  thus  leads  to  the  serious  accident  of  its  breaking 
during  extraction,  which,  setting  free  the  embryos — Mhether  the  Avorm 
be  dead  or  not — may  lead  to  gangrene  or  death.  This  accident  may  some- 
times end  more  fortunately  by  the  discharge  of  the  worm  later  on,  after 
the  formation  of  a  new  tumor.  The  favorite  site  (90  per  cent.)  for  the 
extrusion  of  the  worm  is  the  foot,  preferably  the  heel,  but  it  may  escape 
from  the  leg  or,  exceptionally,  from  any  part  of  the  body.  While  only 
one  worm  is  the  rule,  t^No,  or  ver}'  rarely  even  fifty,  have  been  noted. 

The  female,  \\  hich  produces  the  symptoms,  has  a  slightly  convex  head, 


3rADUBA  FOOT.  353 

a  pointed  tail,  is  about  oue-teuth  of  an  incli  in  diameter,  and  varies  in 
length  from  one  to  six  feet,  measuring  upon  tlie  average  from  two  to 
two  and  a  half  feet.  Crowded  ^vith  embryos,  upon  escaping  from  its 
human  host,  if  reaehing  water,  these  penetrate  a  minute  crustacean  of 
the  genus  Cyclops,  and  there  reach  full  larval  development.  When 
their  crustacean  host  is  swallowed  the  larvae  develop,  conjugate,  and  the 
female  migrates  through  the  muscles,  the  male  probably  perishing  and 
being  passed  with  the  faeces.  From  nine  to  ten  months  are  consumed 
within  the  deep  tissues  in  the  develoj)mcnt  of  the  female  before  she 
appears  superficially. 

Diagnosis. — This  can  only  be  made  Ijy  detecting  the  worm  by  the 
touch  and  noting  its  change  of  position. 

Prognosis. — Unless  attended  l)y  severe  inflammation  from  the  start, 
or  the  worm  is  broken  during  extraction,  recovery  readily  occurs. 

Treatment. — Antiseptic  poulticing  will  facilitate  opening,  when  the 
worm  must  be  gently  drawn  out,  ceasing  the  eitbrt  if  any  resistance  is 
felt :  wind  what  has  been  withdrawn  around  a  small  stick,  which  should 
be  given  one  or  more  turns  each  day  until  the  worm  is  extracted,  scru- 
pulously avoiding  breaking  it.  Non-irritating  antise])tic  dressings  may 
be  applied.  Asafo?tida  in  large  doses  internally  is  said  to  kill  the  worm. 
The  violent  inflammation  so  commonly  following  rupture  of  the  worm 
must  be  treated  upon  general  surgical  j)rinciples.  If  gangrene  occur, 
amputation  may  become  neces.sary. 

Madura  Foot  (Mycetoma;  Fungous  Disease  of  India). 

Endemic  in  certain  portions  of  India  and  occurring  only  in  natives, 
this  disease  most  frequently  attacks  males,  especially  field-workers  and 
those  who  pursue  their  avocations  with  bare  feet.  Although  found  at 
any  age,  it  is  rare  below  puberty.  Some  trivial  injury,  as  a  prick  or  an 
abrasion,  is  alleged  as  the  exciting  cause,  but  often  neither  predisposing 
nor  exciting  cause  can  be  detected.  From  the  ditterence  in  color  two 
forms  have  been  described — viz.  the  pale  and  the  black,  the  latter  being 
the  more  common. 

Pathology. — Vandyke  Carter's  original  explanation  no  longer  holds 
good — viz.  that  the  disease  results  from  the  fungus  Cluonyphe  (Jarteri — 
but  his  later  suggestion,  made  in  1886,  has  received  confirmatory  proof 
by  the  recent  work  of  Kauthack,  who  has  shown  IMadura  foot  to  be  a 
variety  of  actinomycosis,  his  conclusions  being  as  follows  :  "  That  (1)  the 
fish-roe  masses  are  undoubtedly  a  form  of  actinomyces ;  (2)  the  black 
masses  in  their  most  perfect  shape  are  also  und(iul)tedly  of  this  natui'e, 
but  in  a  state  of  degeneration  ;  (3)  a  degenerated  form  of  the  yellow 
variety  is  occasionally  found,  in  ap])earance  not  wholly  unlike  these  black 
masses,  so  that  the  relation  between  all  these  forms  seems  to  be  fully 
e-stablished."  '  Fibroid  and  fatty  changes  so  alter  the  tissues  that  it  is 
often  diflicult  to  distinguish  them  apart,  all  being  changed  into  an  oj)aque, 
hoinogenetius,  gelatinous  mass,  many  of  tlie  bones  being  replaced  by 
fibrous  tissue.  The  muscular  tissue  is  the  least  altered,  while  the  adipose 
tissue  is  much  increased  and  often  contains  pigment-granules.  The 
sinuses  which  riddle  the  foot  in  all  directions  are  peculiar  in  that,  while 

^Journal  of  Pathology  and  Bacteriolofft/,  vol.  i.  p.  140,  et  seq. 
Vol.  I.— 23 


354      DIAGNOSIS  AND   TREATMENT  OF  PERNIO,   OR   VIIILULAIN. 

2>ic'reing  tlie  bones  "as  if  tlicy  liad  hecn  drilled,"  their  osseous  walls  are 
often  unaft'ected  with  the  degeneration,  and  that  they  open  into  single  or 
multi|)le  rounded  cavities  eontaining  numerous  granides,  which  latter  are 
likewise  scattered  over  the  sinus-walls  or  arc  free  in  their  luniina.  The 
lighter  granules  consist  of  a  central  close  mycelial  netw()rk  "and  a  peri- 
peripheral  fringe  of  more  transparent,  more  or  less  glassy,  rays."  The 
black  granules  are  chiefly  formed  of  the  inorganic  constituents  of  the 
tissues,  ]>igment,  and  the  more  or  less  altered  fungus. 

Symptoms. — The  j>art  attacked  is  nearly  always  the  foot  or  leg,  next 
in  frequency  the  hand  or  arm,  ^'ery  rarely  the  shoulder  or  scrotimi.  The 
onset  varies.  Thus,  a  toe  or  finger,  or  the  foot  itself,  may  l)e  attacked, 
very  little  swelling,  redness,  or  circumscribed  induration  being  noticeable. 
Again,  either  a  superficial  or  deep  ]ia])ule,  pustule,  or  tubercle  may  ap- 
pear, moderately  tender,  which  on  rupturing  discharges  pus,  but  later  the 
characteristic  granules.  Occasionally  a  subcutaneous  mottling  exists  for 
some  time  before  the  skin  gives  way.  Slowly,  accom])anied  by  severe 
pains,  the  foot  becomes  enormously  swollen,  distorted,  and  useless ;  the 
arch  of  the  ibot  gives  way  from  destruction  of  the  bones,  so  that  even 
over-extension  of  the  toes  takes  place.  Scattered  over  the  skin  are  small 
elevations,  whose  centres  are  the  orifices  of  the  sinuses  leading  into  the 
cavities  before  mentioned.  These  latter  may  be  near  the  surface  or  deeply 
seated,  and  sometimes  involve  the  lower  ends  of  the  tibia  and  fibula  as 
well  as  the  bones  of  the  foot.  The  discharge  is  sero-purulent,  and  con- 
tains the  characteristic  white,  yellow,  black,  or  very  rarely  pink  or  red 
granules  resembling  fish-roe.  The  granules  also  lie  scattered  on  the  sur- 
face around  the  orifices  of  the  sinuses.  It  may  take  six  to  twelve  years 
completely  to  disorganize  the  member,  but  the  disease  tends  to  a  fiital 
termination. 

Diagnosis. — Commencing  as  a  tubercle  or  pustule,  until  either  rup- 
tures it  might  be  difficult  to  decide  between  mycetoma  and  the  Guinea- 
worm  disease,  but  the  absence  of  the  worm  and  the  roe-like  material  in 
the  discharge  would  settle  its  nature.  In  advanced  cases  the  fact  of  an 
extremity  being  concerned,  the  marked  swelling,  the  numerous  sinuses, 
and  the  characteristic  granular  discharge  should  suffice. 

Prognosis. — If  left  to  nature,  complete  disorganization  of  the  mem- 
ber will  result. 

Treatment. — When  superficial,  early  free  curetting  has  proved  effi?et- 
ual.  If  only  a  finger  or  toe  is  involved,  its  prompt  removal  will  usually 
suffice.  In  more  advanced  cases  amputation  is  the  sole  resort,  and,  as 
the  leg-bones  niay  have  undergone  change  much  higher  than  external 
appearances  would  indicate,  the  bones  must  be  removed  well  above  any 
suspicious  point. 

Pernio,  or  Chilblain. 

This  is  produced  by  the  sudden  ap])lication  of  cold  to  any  exposed 
portion  of  the  body  where  the  circulation  is  impaired.  The  vascular 
condition  maybe  due  to  a  weak  heart  or  to  the  distance  of  the  part  from 
the  centre  of  the  circulation,  as  in  the  case  of  the  ears  or  toes.  In  the 
latter  instance  the  compression  of  the  foot-gear  also  favors  antemia. 
Sudden  aj)proach  to  the  fire  after  exposure  is  a  common  cause,  owing  to 
the  change  of  tempei'ature  causing  intense  congestion  from  vasomotor 


FROST-BITE.  355 

paresis.  Cliildren  ^vhose  power  of  g;enerating  heat  is  feeble,  and  those 
adults  who  resemltle  them  in  this  particular,  are  most  lialile  to  chilblain. 

Symptoms. — The  mild  form  amounts  only  to  a  moderate  redness  of 
the  skin  and  some  swelling,  with  hi'at  and  itching  of  tiie  parts,  which  dis- 
a])pear  spontaneously.  Another  variety  is  evidenced  l)v  marked  swelling 
and  redness,  the  latter  often  assuming  a  purplish  hue  due  to  venous  con- 
gestion. The  heat,  itching,  and  tingling  pain  are  very  marked,  especially 
when  the  parts  become  warm  after  the  slightest  chilling.  This  form 
usuallv  does  well  with  proper  treatment.  In  its  worst  form  pernio 
closely  rcsendiles  frost-bite  from  the  severity  of  the  inflammation,  blebs 
forming  which  on  rupturing  leave  indolent  ulcers,  sometimes  covered 
with  sloughs,  "  yielding  a  thin  ichorous  or  sanious  discharge." 

Treatment. — Prophvlaxis  is  important,  and  consists  in  woollen  cover- 
ings for  the  feet  and  appropriate  ones  for  the  hands  and  exjiosed  parts. 
Local  stimulation  of  the  circulation  by  dry  frictions  or  with  alcohol, 
spirits  of  camphor,  or  soap  liniment  is  useful  as  a  i)rophylactic.  Entei- 
ing  a  warm  room  or  coming  close  to  a  fire,  even  after  exposure  to  slight 
cold,  must  be  avoided.  When  the  milder  form  is  threatened  gentle  fric- 
tion with  snow  or  ice-water  until  reaction  begins  to  be  established,  in 
a  cold  or  only  moderately  warm  room,  is  to  be  rcconnnendcd,  followed 
by  an  alcohol  dressing,  or  even  tincture  of  iodine  when  no  Idisters 
have  formed.  AMicre  jjcrsistent  congestion  with  tendency  to  swelling, 
attacks  of  itching,  etc.,  repeatedly  occur,  the  constant  current  and  local 
applications'  to  produce  contraction  of  the  paretic  vessels,  coupled  with 
tonics  and  measures  calculated  to  invigorate  the  circulation,  will  usually 
give  relief.  If  ulceration  or  sloughing  occur,  it  must  be  treated  ujjon 
general  principles. 

Frost-bite. 

This  term  includes  the  more  serious  effects  resulting  locally  from  the 
abstraction  of  heat — miscalled  "  application  of  cold."  Exposure  to  low 
temperatures  causes  destruction  of  jiarts  in  two  ways — /.  e.  (1)  directly, 
by  freezing  the  tissues  so  thoroughly  and  for  such  a  time  that,  even  when 
most  cai'efully  treated,  after  thawing  they  are  found  to  be  dead  ;  and  (2) 
more  connnonly  indirectly,  gangrene  resulting  partly  from  the  lowered 
vitality,  but  chiefly  from  the  subsequent  inflanmiation,  causing  strangu- 
lation and  death  of  the  enfeebled  tissues  by  the  exudates  ;  in  other  words, 
so-called  "  inflammatory  gangrene  "  determines  the  sloughing  or  sphac- 
elus. The  effect  of  cold  being  to  promote  adhesion  of  the  leucocytes, 
cajiillary  thromboses  are  readily  formed,  favoring  and  often  determining 
gangrene. 

Symptoms. — First,  numbness  with  loss  of  power  is  felt,  usuall}'  in 
peripheral  parts,  as  the  nose,  ears,  fingers,  or  toes ;  then  tingling  and  a 
sensation  of  weight  are  noticed.  Inspection  now  shows  that  the  parts 
are  bleached  white  and  icy  cold  to  the  touch,  all  sensation  being  lost. 
If  ho])elessly  frozen,  discoloration  and  swelling  follow  the  ]irimarv 
blanching ;  the  parts  next  shrivel  and  contract ;  a  line  of  separation  fol- 
lows ;  putrefactive  changes  ensue ;  and  the  nose,  ears,  feet,  or  hands  may 

'Camphorated  soap  liniment,  turpentine  witli  copaiba,  lead-water,  alum  in  solution, 
with  numerous  similar  suhstances,  have  been  all  vaunted,  but  careful  prophylaxis  is  requi- 
site to  render  any  treatment  of  avail. 


356  SYMPTOMS  AND   TREATMENT  OF  GANGRENE. 

be  spontant'ou.sly  amputated.  When  too  rapid  tliawing  jw'ecipitates  gan- 
grene, or  judicious  eif'orts  fail  to  maintain  the  vitality  of  the  part,  the 
primary  swelling  and  ah)iormal  sensibility  are  followed  by  intense  in- 
flanniiatory  phenomena  ;  blebs  form  ;  tiie  pain  ceases;  the  skin  becomes 
mottle(l  and  discolored  ;  and  finally  the  parts  manifest  all  the  phenomena 
of  moist  gangrene. 

Treatment. — This  nnist  secure  a  most  gradual  restoration  of  circula- 
tion, and  with  this  the  power  of  (calorification.  Sudden  increase  of 
temperature  will  induce  such  a  paretic  condition  of  the  vasomotor  sys- 
tem as  will  produce  stasis,  coagulation-necrosis,  and  gangrene.  Com- 
mencing by  frictions  with  snow,  then  immersion  of  the  part  in  water,  all 
treatment  being  conducted  in  a  cold  apartment,  the  temperature  of  the 
ap])lications  and  of  the  room  must  be  gradually  raised  nntil  the  somatic 
and  local  temperatures  have  nearly  attained  the  normal,  when  applica- 
tions which  tend  to  stimulate  to  action  the  paretic  local  vasomotor 
apparatus  are  indicated,  such  as  diluted  alcohol  or  diluted  spirits  of 
camphor.  Elevation  of  the  parts,  which  should  be  swathed  in  raw  cot- 
ton, M'ill  tend  to  relieve  the  venous  stasis  by  favoring  the  return  of 
blood.  Warm  stimulating  drinks,  as  hot  coffee,  aromatic  spirits  of  ammo- 
nia, or  whiskey  diluted  with  hot  water,  are  now  indicated.  Should 
inflammation  run  high,  threatening  gangrene,  antiseptic  irrigations  may 
be  employed,  and  in  any  event  asepsis  and  antisepsis  must  be  maintained 
throughout.  If  gangrene  results  despite  all  efforts,  the  constitutional 
and  local  treatment  advised  on  pages  358,  359  should  be  adopted. 

Gangrene. 

Sphacelus,  gangrene,  mortification,'  and  sloughing  are  all  terms  which 
indicate  the  death  of  tissues  in  greater  or  smaller  masses.  This  condition 
is  always  the  result  of  two  factors  combined  in  varying  proportions — 
viz.  an  insufficient  supply  of  nourishment  to  the  cells,  producing  a  lowering 
of  tissue-cell  vitality,  and  their  mechanical  destruction.  The  deprivation 
of  pabulum  may  be  induced  in  many  ways.  Thus,  the  main  artery  of 
tlie  limb  may  be  occluded  suddenly  or  gradually ;  the  main  veins  may 
become  thrombosed,  preventing  the  return  of  blood,  or  both  conditions 
may  obtain  :  again,  inflammation  may  lead  to  such  free  exudation  that 
the  blood-vessels,  plasma-channels,  and  even  the  cells  themselves,  may 
be  so  compressed  as  to  be  unable  to  maintain  their  vitality.  If  to  this 
last  condition  be  added  death  of  some  of  the  cells  by  mechanical  injury, 
or  their  lowered  vitality  brought  about  by  other  predisposing  conditions, 
mortification  still  more  readily  occurs.  In  certain  injuries  of  the  cerebro- 
spinal axis  or  of  the  peripheral  nerves,  local  gangrene  often  supervenes, 
precipitated  by  pressure,  but  probably  predisposed  to  by  interference 
with  vasomotor  equilibrium. 

Two  types  of  gangrene  exist — the  moist  and  the  drj' — the  presence 
or  absence  of  fluids  in  the  tissues  when  gangrene  occurs  determining  to 
which  class  the  case  belongs,  the  difference  being  purely  a  physical  one. 

Dry  Gangrene. — This  is  usually  caused  by  a  gradual  diminution 

•  Necrosis  is  a  term  which  should  be  restricted  to  death  of  bone  or  to  g.ingrene  of 
the  viscera  where  the  absence  of  putrtifactive  organisms  admits  of  absorption  of  tlie 
dead  tissues,  a  scar  remaining. 


GANGREyE.  357 

of  the  arterial  supply,  the  venous  blood  having  free  egress.  Occasionally 
dry  gangrene  follows  embolism.  Because  atheroma  leads  to  such  arterial 
changes  as  interfere  with  tlic  vascular  supply,  and  as  this  disease  is  more 
common  in  the  old,  in  whom  the  feeble  heart  also  predisposes  to  malnu- 
trition of  the  peripheral  tissues,  dry  gangrene  is  often  called  "  senile 
gangrene ; "  but  with  the  same  physical  conditions,  notably  in  chronic 
ergotism,  typical  gangrene  of  the  feet,  hands,  nose,  and  tips  of  the  ears 
mav  occur  in  the  young.  Vasomotor  spasm,  a  feeble  heart,  and  ill- 
nourished  tissues  all  result  from  living  for  long  periods  on  spurred  rye. 

Symptoms. — Coldness  and  numbness  of  the  feet,  with  cramps  in 
tliem  or  in  the  calf-nuisclcs,  are  fre(pient  prodromes.  After  bruising  a  toe, 
trimming  a  corn  too  closely,  or  from  the  friction  of  the  boot,  congestion 
and  inflammation  occur.  The  blush  deepens,  becomes  purplish  ;  the 
part  is  insensitive  and  cold,  but  oftentimes  severe  pain  is  experienced  in 
the  neighboring  tissues.  The  dead  parts  dry,  shrivel,  and  blacken,  emit- 
ting the  odor  of  decomposition.  An  inflammatory  line  of  demarcation 
marks  the  boundary  between  the  dead  and  living  tissues,  shifting  upward 
as  the  disease  progresses  until  it  is  arrested,  when  septic  ulceration  soon 
establishes  a  line  of  separation.  The  gangrene  may  be  restricted  to  one 
toe  or  may  gradually  involve  the  whole  foot  and  leg,  but  usually  stops 
just  below  the  knee — /.  c.  about  the  bifurcation  of  the  popliteal  artery. 
Little  if  any  fever  may  attend  upon  destruction  of  one  or  two  toes,  but 
where  much  tissue  dies  septic  fever  becomes  more  or  less  pronounced. 
Pain  varies  from  a  mere  burning  sensation  to  such  agony  as  to  require 
the  constant  use  of  morphine. 

Moist  Gangrene. — Sudden  obstruction  to  the  main  arterial  current, 
as  by  embolism  or  ligature,  interference  with  the  return  of  the  venous 
blood,  and  cutting  otf  of  the  ultimate  blood-supply  to  the  tissues  by 
the  pressure  of  inflammatory  exudates  are  the  usual  causes.  Because 
moist  gangrene  so  often  follows  traumatism  it  has  been  sometimes  called 
"traumatic  gangrene."  The  disease  may  occur  either  as  a  localized 
traumatic  or  a  spreading  traumatic  gangrene. 

Localized  Traumatic  (Jaiif/rcne. — The  injury  unquestionably phj^sically 
devitalizes  portions  of  the  tissues,  but  the  chief  destruction  results  from 
the  pniducts  of  the  scjitic  inflannnati(jn  so  compressing  the  vascular  sup- 
ply (capillary  and  arterial)  to  the  tissue-cells  that  they  die  :  doubtless  fer- 
ments and  ptomaines  also  play  a  part.  The  damaged  tissues  perish  with 
some  of  the  surrounding  parts  from  the  inflammation,  but  the  process 
docs  not  extend  indefinitely. 

Symptoms. — Tiie  liurning  pain  often  preceding  mortification  entirely 
ceases ;  the  skin  is  cold,  pale,  insensitive,  then  becomes  mottled  green  or 
red,  and  finally  livid.  Blebs  form  containing  brownish  serum.  Wlien 
the  blebs  are  ruptured  they  leave  a  dermis  resembling  moist  smoked 
beef;  moreover,  before  rujiture  they  can  be  slipped  around  over  the  dead 
derm,  because  the  devitalized  epithelium  reatlily  separates,  thus  being 
distinguishable  from  the  lilisters  forming  after  inflannnation.  The  sur- 
faces of  the  wound  become  puljiy,  yellowish  or  grayish,  and  exude  a 
profuse  oifensive  discharge,  and  the  dead  part  undergoes  putrefactive 
changes.  The  dead  tissues  contrast  sharply  M'ith  the  living,  intensely 
reddened  tissues,  separation  occurring  from  septic  ulcerative  inflammation 
unless  the  patient  dies  from  sapriemia,  which  is  unusual,  and  recovery 


358  SYMPTOMS  A\D   TREATMENT  OF  GANGRENE. 

ensues.  Hemorrhage  is  not  common,  bw^ause  softening  of"  tiie  tln-onihi 
wliieli  form  in  the  vessels  by  the  action  of  the  products  of  germ-growtii 
rarely  occurs.  The  prognosis  is  better  wheu  the  original  injury  has  ])ro- 
duced  either  an  extensive  wound  or  many  wounds  of  tiie  soft  parts,  which 
allow  vent  for  the  poison-laden  discharges. 

Spi'eadiiir/  Trauiiiaiic  Gangfene. — This  results  from  specific  infection 
of  tissues  whose  vitality  has  been  lowered  by  severe  traumatism,  espe- 
cially if  the  main  vessels  are  destroyed.  Where  the  vessels  are  intact 
the  rapidly-spreading  infective  inflannnatiou  destroys  the  tissues,  partly 
by  strangulation  of  their  minute  lilood-supply,  lint  chiefly  by  the  effects 
of  the  ptomaines,  peptonizing  ferments,  etc.  which  are  generated  and 
confined  under  pressure.  Hence  severe  crushes  with  but  trivial  division 
of  the  soft  2>arts  are  most  dangerous.  The  infection  is  often  a  mixed 
one,  but  sometimes  one  only  of  the  pathogenic  germs  is  present.  The 
cellular  tissue  is  that  which  is  chiefly  attacked  ;  hence  the  disease  is  more 
extensive  than  external  appearances  would  indicate. 

Symptoms. — Tiie  linil)  becomes  tense  and  brawny,  the  skin  of  a  dull 
reddish  brown,  variegated  with  streaks  and  spots  of  green  or  black. 
Emphysematous  crackling  can  often  be  felt,  which  extends  somewhat 
above  the  point  of  apparent  skin-involvement,  and  usually  higher  upon 
the  inner  side  of  the  limb.  The  gangrene  extends  witli  lightning  speed, 
sometimes  in  less  than  forty-eight  hours  involving  a  wliolc  lower  limb 
with  half  of  the  abdomen  and  trunk.  So  soon  as  the  local  condition  is 
fairly  started,  owing  to  the  absorption  of  enormous  doses  of  ptomaines 
and  toxines  by  the  lymphatics  of  the  cellular  tissue,  which  are  un- 
blocked by  any  exudate  upon  the  proximal  side,  marked  constitutional 
symptoms  of  saprremia  develop,  which  soon  terminates  fatally  unless  art 
intervenes. 

VoriKfifidional  St/mptoms. — If  the  process  be  extensive  or  involves 
an  important  organ,  the  heart  acts  feebly,  the  pulse  is  quick,  compressible, 
and  small,  the  tongue  dry,  brown,  and  covered  with  sordes  which  extends 
around  the  teeth  and  upon  the  lips ;  in  fact,  a  typhoid  state  exists. 

Treatment. — If  possible,  remove  the  determining  cause,  which  can 
often  be  done  by  strict  antisejjsis  after  injuries,  especially  in  the  aged,  and, 
in  threatened  gangrene  of  a  crushed  limb,  by  incisions  which  will  give  exit 
to  septic  discharges  and  I'elieve  strangulation  of  tissue.  If  obstruction 
of  the  main  vessel  has  occurred,  favor  the  establishment  of  the  collateral 
circulation  b}'  moderate  elevation  of  the  limb,  warmth,  and  cardiac  stim- 
ulants. Thorough  disinfection  of  gangrenous  parts,  followed  by  dry 
antiseptic  dressing,  such  as  iodoform  or  boric  acid  combined  with  ]30w- 
dered  charcoal,  often  jn-cvents  septic  infection.  Inflammatory  products 
must  be  evacuated  by  incisions  carried,  when  possible,  through  the  dead 
tissues.  When  the  process  tends  to  self-limitation  in  senile  gangrene, 
delay  is  advisable,  removing  the  dead  tissues  from  time  to  time ;  second- 
ary amputation  may  be  done  later  if  the  stump  does  not  heal.  When 
senile  gangrene  spreads,  although  an  amputation  lielow  the  knee  may 
succeed,  removal  of  the  limb  at  the  lower  third  of  the  tliigh  is  better, 
because  the  blood-supjily  to  the  Haps  comes  from  the  profunda  femoris. 

In  embolic  gangrene  it  is  best  to  delay  until  a  line  of  demarcation 
forms,  otherwise  an  unnecessary  sacrifice  of  parts  may  result. 

For   localized  gangrene — ;".  e.  sloughing  of  the  skin  and  subjacent 


i? 


& 


GANGRENE.  359 

tissues — nothing  is  requisite,  except  incisions  through  or  partial  removal 
of  the  dead  tissue  to  evacuate  pus,  until  the  line  of  separation  forms. 
Gangrene  caused  by  crushing  of  a  limb  demands  immediate  amjnitation 
if  the  process  is  rapidly  extending.  If,  however,  it  is  localized,  the 
general  condition  of  the  patient  must  decide  what  nuist  be  done — *.  c.  if 
septic  absorption  is  producing  marked  constitutional  eftects  and  the 
patient  can  stand  the  shock,  am})utate  ;  if  not,  strive  to  improve  the 
general  condition,  endeavoring  to  prevent  further  absorption  of,  and  to 
eliminate,  all  ptomaines  which  have  been  already  taken  up.  The 
only  measure  otfering  any  ]irosj>cct  of  success  in  spreading  traumatic 
gangrene  is  prompt  amputatimi  far  above  the  apparent  external  limits 
of  the  disease.  Sometimes,  as  at  the  shoulder-joint,  flaps  may  be 
successfully  fashioned  out  of  infiltrated,  oedematous  tissue.  The  flaps 
must  be  long,  and  if  there  be  doubt  if  all  infected  tissue  has  been 
removed,  primary  suturing  had  better  be  avoided,  antiseptic  irrigation 
employed,  and  secondary  suturing  resorted  to  later.  Alcohol  and  cardiac 
stinuilants,  with  quinine  and  opium  to  secure  sleep,  must  be  given. 
Large  quantities  of  easily-assimilable  food  should  be  provided.  Care 
must  be  taken  to  see  that  the  kidneys  and  bowels  eliminate  properly. 

Hospital  Gaxgrexe  is  an  infective  microbie  disease  which  usually 
attacks  an  open  wound,  but  has  followed  subcutaneous  injuries.  The 
disease  is  hardly  known  now,  owing  to  the  avoidance  of  overcrowding  of 
patients  and  to  antisepsis,  the  vii'us  probably  being  a  special  micrococcus 
which  may  reacli  the  wound  through  the  medium  of  the  air,  the  nurse's 
or  surgeon's  hands,  instruments— above  all,  sponges.  The  microbes, 
in  both  masses  and  chains,  are  jjresent  in  the  slough  and  the  surrounding 
tissues,  but  not  in  the  blood.  Three  distinct  forms  have  been  described 
— viz.  the  dipiitheritic,  tiie  ulcerative,  and  the  Jjulpv.  The  first  variety — 
thought  by  some  to  be  a  mild  form  of  hospital  gangrene,  but  by  otiiers 
to  result  from  a  diiferent  and  specific  micrococcus — produces  a  coagula- 
tion-necrosis of  the  graiuilations,  the  wound-surface  being  covered  Avith 
a  yellowish  or  grayish-white,  tenacious  pseudo-membrane  ;  the  discharge 
is  at  first  scanty,  but  later  becomes  more  almndant  and  watery.  This 
form  is  but  slightly  contagious,  and  only  j)r(jduces  systemic  results  by 
jitomaVne  absorption.  When  the  sloughs  sc])ai'ate  a  deep  excavation  is 
left,  but  during  the  whole  process  there  is  little  inflammation  in  the  sur- 
rounding tissues.  The  ulcerating  vai'iety  is  characterized  by  a  rapidly- 
spreading,  rather  superficial  ulcer,  covered  by  unhealthy  grayish  gran- 
idations,  with  inflamed,  reddened,  sharji-cut  edges :  the  discharge  is  free 
and  excessively  offensive.  The  pulpy  form  is  often  epidemic,  and  when 
attacking  an  open  wound  causes  gr(>at  swelling  of  the  granulations. 
Pultaceous,  ash-gray,  adherent  sloughs  soon  form,  extending  rapidly  in 
depth  and  extent,'  with  a  profuse,  thin,  greenish  or  sanious  offensive 
discharge.  The  surrounding  tissues  are  dusky-red,  swollen,  (edematous, 
the  margins  of  the  ulcerated  surface  being  sharp-ent,  elevated,  and 
excessively  tender.  The  main  vessels  may  l)ecome  eroded,  producing 
hemorrhage,  and  even  large  joints  may  be  laid  open.  Profound  consti- 
tutional symptoms,  assuming  a  tyj)hiii(l  character,  due  to  ptomaine 
absorption,  set  in  early,  sometimes  producing  death  in  a  few  hours. 

Treatment. — Prompt  isolation  must  be  effected.  Where  numbers 
of  patients,  as  soldiers,  are  attacked,  tents  or  huts  are  preferable,  even 


360  SYMPTOMS  AND  TREATMENT  OF  GANGRENE. 

ill  cold  weather,  to  crowded  wards.  Tlie  patient's  strenijtli  must  he  sus- 
tained hy  food,  stimulants,  quinine,  strychnia,  and  (lii;-italis,  and  opium 
given  to  ohtain  sleep.  The  enuuictorics — hy  which  the  ahsorhed  jitoiuainos 
may  he  eliminated — should  be  stimulated.  Locally,  in  the  diphtheritic 
form,  efficient  disinfection,  followed  by  the  free  use  of  iodoform,  will 
often  suffice,  but  in  the  more  severe  varieties  the  patient  must  be  anies- 
thetizcd,  all  sloughs  cleared  away,  and  what  still  adheres  of  them,  with 
the  surrounding  infected  area,  nuist  l)e  thoroughly  destroyed  with  Ijromiiie, 
nitric  acid,  or  the  thermo-eautcry.  After  this,  free  dusting  with  ioiloform 
and  the  careful  use  of  wet  antiseptic  dressings  will  bring  about  recovery 
if  the  systemic  infection  be  not  too  great,  provided  all  infected  tissue  has 
been  destroyed;  if  recrudescence  of  the  local  symptoms  occurs,  a  repetition 
of  the  caustic  treatment  is  indicated. 

Bed-80RES,  or  Decubitus. — Tliis  is  a  moist  gangrene,  produced  by 
pressure  mechanically  interfering  with  the  access  of  blood  to  the  tissues 
of  patients  lying  for  a  considerable  time  in  one  position.  The  weak 
heart  and  tissues  of  such  individuals  predispose  to  gangrene,  bed-sores 
occurring  most  frequently  during  acute  or  chronic  exhausting  ailments 
or  in  ])arts  deprived  of  nerve-influence,  as  after  fracture  of  the  spine. 
When  the  slough  has  separated  the  ulceration  sometimes  extends  widely 
and  deeply,  and  may  end  in  death  by  j)y:emia,  hectic,  or  exhausting  (hs- 
charges.  The  most  common  sites  for  bed-sores  are  over  the  coccyx  and 
sacrum,  the  great  trochanters,  the  shoulder-blades,  malleoli,  and  back  of 
the  heels. 

Treatment. — Bed-sores  can  usually  be  prevented  by  frequent  bathing 
of  parts  subjected  to  pressure,  covering  the  same  with  soap  plaster  spread 
upon  wash-leather,  removing  pressure  by  padded  or  air  rings,  pillows, 
etc.,  and  frequent  change  of  position.  Once  formed,  removal  of  pres- 
sure as  far  as  possible,  disinfection,  and  dry  dressings  must  be  tried. 
After  separation  of  the  sloughs  the  resultant  ulcer  must  be  treated  as 
recommended  elsewhere. 

White  Gangrene. — The  etiology  is  obscure,  and  it  is  said  to  be 
due  to  some  general,  not  local,  cause.  It  is  a  recurrent  disease,  and 
appears  during  early  adult  life  in  those  who  are  feeble  and  ill-fed.  It 
is  probably  due  to  some  peculiar  localized  vasomotor  condition  producing 
a  nearly  perfect  anaemia  of  the  dead  parts. 

Symptoms. — Although  any  part  may  be  the  seat  of  the  disease,  the 
extremities  are  the  i)arts  usually  attacked,  and  by  preference  the  lower 
ones.  Pain,  following  the  course  of  the  main  nerves  if  a  limb  is 
attacked,  jjrecedes  each  attack,  lasting  for  weeks  or  even  months. 
Irregular  menstruation  and  various  nervous  symptoms  are  observed 
in  females.  Locally,  a  circumscribed  spot  on  the  limb,  usually  circular 
in  outline,  or  a  toe,  becomes  dull  A\'hite  ;  the  skin  soon  dries  and  shrivels  ; 
b}'  a  septic  inflammation  a  red  line  of  separation  forms,  and  the  slough 
comes  away,  leaving  a  granulating  surface.  When  only  the  skin  is 
involved,  the  disease  is  comparatively  trivial,  but  when  all  the  soft 
parts  down  to  the  bones  are  destroyed,  it  is  a  serious,  and  sometimes  a 
fatal,  atfection. 

Treatment. — This  does  not  differ  from  what  is  recommended  for  the 
other  forms,  but  the  constant  current  is  suggested,  so  as  to  modify  the 
vasomotor  condition  of  the  parts. 


GANGRENE.  361 

Glvcosttria. — Tlic  relation  borne  by  glycosnria  to  ganp;rene  may  be 
briefly  stated  thus  :  While  patients  whose  urine  contains  sugar  are  more 
liable  to  sutler  from  gangrene  whieii  pursues  a  rapid  course,  because  the 
tissues  of  diabetics  are  weak  and  prohalily  attbrd  favorable  pabulum 
for  the  growth  of  germs,  the  mere  presence  of  sugar  does  not  cause  the 
disease.  Again,  diabetics  very  frequently  have  arterio-sclerosis '  and  a 
variety  of  peripheral  neuritis  closely  resembling  that  produced  by 
alcohol.  The  neuritis"  attacks  liy  preference  the  nerves  of  the  lower 
extremities,  giving  rise  to  perforating  idcer,  the  knee-jerks  being  tem- 
porarily or  permanently  abolished,  but  the  Argyll -Robertson  pupil  has 
not  been  observed.  Gangrene  occurs  in  patients  with  sugar  in  the  urine 
wlio  belong  to  three  main  classes,  as  pointed  out  by  Godlee — viz.  (!) 
simple  dialectics  ;  (2)  gouty  persons  with  sugar  in  the  urine  ;  and  (3) 
diabetics  who  are  also  gontv.  The  determining  causes  are  inflammation 
(perhaps  very  slight),  coinciding  with  either  arterio-sdcrosis  or  neuritis, 
the  first  variety  usually  being  painful  and  spreading  rapidly,  the  neurotic 
form  being  slower  and  comparatively  painless. 

Treatment. — All  operative  interference  has  been  opposed  until  re- 
cently, but  numerous  observers  have  shown  that  when  painful  and  rap- 
idly spreading — /.  c.  when  arterio-sdcrosis  is  present  with  plugging  of 
the  vessels — a  prompt  knee  or  thigh  amputation  often  saves  life,  and  the 
sugar  sinks  to  a  minimum  after  healing,  when  during  the  gangrenous 
inflammation  neither  medicine  nor  diet  availed.  The  chief'  causes  of 
failure  are  a  too  low  amputation  through  the  area  whose  main  vessels  are 
thrombosed,  including  infected  tissues  in  the  flajis,  after  infection,  and 
late  operation,  especially  in  those  in  whom  the  urine  has  become  albu- 
minous. In  the  neurotic  form,  where  one  or  two  toes  are  involved, 
spontaneous  separation  and  recovery  sometimes  occur,  and  in  this 
variety,  and  in  that  starting  from  a  perforating  ulcer,  delay  with  I'cmoval 
of  the  dead  parts  and  antisepsis  is  permissible — nay,  often  advisable. 
Dietetic  and  medicinal  treatment  after  operation  is  requisite,  often  con- 
verting the  more  acute  into  the  chronic  form  of  diabetes,  and  in  the 
chronic  form,  where  of  course  tlie  prognosis  is  better,  life  may  be  pro- 
longed for  many  years.^ 

Symmetricai>  Gangrene,  or  Raynaud's  Disease,  is  a  rare  affection, 
believed  to  arise  from  a  condition  of  the  vasomotor  apparatus  in  which  it 
reacts  abnormally  to  cold  or  other  irritants,  producing  by  reflex  action 
persistent  vaso-constrictor  spasm.  Although  attacking  any  peripheral 
parts  exposed  to  cold,  the  tip  of  the  nose,  an  ear,  the  cheeks,  and  tlie 
tips  of  the  fingers  and  toes  are  the  parts  usually  involved.  Children 
or  young  adults  are  those  usually  attacked. 

Symptoms. — Usually  a  varying  period,  marked  by  intermitting 
attacks  of  pallor,  coldness,  ard  numbness  of  the  parts,  is  noted — i.  e. 
local  sj/ncopc ;  in  many  cases  tlie  next  symptom  is  a  bluish,  congested 
appearance  presented  l)y  the  parts  (local  at<plii/.i-ia),  which  is  accomjm- 

'  Israel  found  this  in  13  of  20  diabetics. 

^  Zierassen  first  suggested  tliis  causal  relation  of  sugar  and  this  form  of  neuritis  in 
188.5,  while  Leydcn  in  1888,  and  later  writers,  have  classified  the  varieties. 

'  The  reader  is  referred  to  vol.  Ixxv.  |ip.  39o-4()8,  and  vol.  Ixxvi.,  of  the  Mcdico-Chi- 
rurgkal  Trans.,  p.  37  et  seq.,  for  two  admirable  articles  on  the  suliject  of  diabetic  gan- 
grene. An  excellent  bibliography  will  be  found,  and  a  resume  of  the  whole  subject  to 
date. 


362       SYMPTOMS  AND   TREATMENT  OF  BURNS  AND  SCALDS. 

nied  by  burning  pain  ;  finally,  gangrene  actually  sets  in,  usually  assum- 
ing till!  dry  form,  but  at  times  it  is  preceded  by  the  formation  of  blebs, 
when  of  course  moist  siuuiirene  or  slousrliiuff  results.  Hsematuria  is  a 
frequently  associated  couilition. 

Prognosis. — As  yet  no  deaths  have  resulted. 

Treatment. — Protection  of  the  jiarts  from  cold  and  the  application 
of  the  constant  descending  current  have  been  alleged  to  have  ])roven 
effectual  in  warding  off  gangrene  when  only  the  stage  of  local  asphyxia 
has  been  reached. 


Burns  and  Scalds. 

Burns  result  from  direct  flame,  radiated  heat,  or  heated  substances ; 
scalds,  from  hot  fluids — /.  c  moist  heat.  The  former  are  apt  to  be  deeper 
and  more  circumscribed,  the  latter  more  superficial  and  covering  a  M'ider 
area,  because  fiuid  flows  over  surfaces  or  is  diffused  by  saturation  of  the 
clothing.  Burns  and  scalds  are  clinically  so  nearly  alike  that  they  will 
be  considered  together. 

The  sun's  rays,  direct  flame,  heated  water,  coffee,  oil,  or  other  dense 
fluids,  molten  metal,  concentrated  acids  and  alkalies,  arc  the  agents  ]iro- 
ducing  these  injuries.  The  effects  dejiend,  first,  upon  the  actual  tem- 
perature, and  second,  upon  the  period  of  application.  Thus,  instanta- 
neous contact  of  even  molten  metal  splashed  so  as  to  touch  the  skin 
produces  vesication,  while  boiling  water  or  oil  kept  in  contact  for  a 
longer  period  will  destroy  the  skin  or  even  deeper  tissues.  While  severe 
scalds  from  water  may  leave  the  cutaneous  hairs,  thus  enabling  us  to  dif- 
ferentiate a  scald  from  a  burn,  the  hairs  may  be  destroywl  by  dense 
liquids,  which  can  be  raised  to  a  much  higher  temperature.  Concen- 
trated acids  and  alkalies  do  not  vesicate,  inflammation  promptly  super- 
vening with  marked  cellulitis,  the  surface  being  covei'cd  with  a  grayish 
exudate.  On  the  face  these  injuries  give  rise  to  rapid  erysipeloid  s\vell- 
ing.  Nitric  acid  stains  the  parts  yellow,  sulphuric  acid  reddish,  and 
carbolic  acid,  after  the  white  .stage  is  past,  of  a  peculiar  coppery  color. 

Constitutional  Effects  of  Burns. — Shock  is  pronounced  in  all  severe 
burns,  varying  according  to  position.  Thus  even  superficial  burns  of 
the  chest,  abdomen,  head,  or  neck,  if  covering  much  surface,  will  produce 
more  shock  than  deep  destruction  of  a  foot  or  hand  :  shock  is  often  fatal. 
A  severe  chill  is  not  uncommon  after  extensive  burns,  and  but  little  pain 
may  be  complained  of;  coma  sometimes  sets  in,  death  resulting  from  cere- 
bral and  other  visceral  congestions.  If  reaction  takes  place,  sthenic 
fever  is  pronounced  in  from  twenty-four  to  forty-eight  hours,  inflamma- 
tion occurring  around  the  burned  spots.  The  congestion  of  the  viscera 
which  occurs  during  the  stage  of  shock  may  run  on  to  inflammation, 
and  perforating  duodenal  ulcer  may  now  commence.  During  and  after 
separation  of  the  slouglis  death  may  result  from  suppuration,  exhaustion, 
and  hectic,  aidetl  perhaps  by  secondary  hemorrhage. 

Capillary  embolism  of  the  kidneys  and  other  organs  by  the  debris  of 
altered  and  destroyed  red  corpuscles  is  supposed  to  explain  certain  cases 
of  sudden  death  after  burns,  because  large  numbers  of  these  cells  have 
been  shown  by  Ponfick  to  be  destroyed  immediately  after  severe  burns 
inflicted  on  animals. 


BUBNS  AND  SCALDS.  363 

Complications  of  Burns  and  Sfalds. — Scalds  of  the  mouth  and  pliar- 
ynx,  chietiy  incurred  bychilch'en  attempting  to  (h'inlv  Ixtiling- water  from 
the  spouts  of  tea-kettles,  and  burns  where  su])erlieated  air  is  inspired, 
often  cause  oedema  of  the  glottis,  commonly  a  fatal  condition  even  after 
tracheotomy  or  intnliation.  Gastro-intestinal  irritation  or  inflammation 
is  frequent,  varying  from  a  little  nausea  and  vomiting,  with  an  occa- 
sional loose  movement,  to  constant  rejection  of  food  and  frequent  stools 
containing  blood.  In  the  latter  condition  duodenal  ulcer  is  jirobable  if 
sudden  collapse  occurs,  especially  if  jiain  and  tenderness  have  been  noted 
in  the  epigastrium. 

The  pathology  oi  gastric  or  duodenal  ulcer  under  such  circumstances 
is  uncertain.  These  lesions  probably  result  from  local  arrest  of  the  cir- 
culation, brought  about  by  thrombosis  of  the  small  vessels  initiated  by 
accumulation  of  the  remains  of  disintegrated  cells  durins;  the  congestion 
occurring  in  shock,  and  the  subse(|uent  digestion  of  these  necrotic  areas 
by  the  digestive  juices.  According  to  Ziemssen,  botli  gastric  and  duodenal 
ulcers  have  sharp-cut  edges,  which  are  indurated  when  the  process  is  old, 
and  are  of  a  funnel-shape  because  more  mucous  membrane  is  gone  than 
muscular  substance,  and  less  muscular  than  serous  tissue  if  actual  per- 
foration has  <)c<'urred,  as  occasionally  happens. 

All)umin  is  always  present  in  the  urine,  excej)t  in  injuries  t)f  the  tirst 
degree  where  no  rise  of  tem])erature  occurs,  the  (juantity  seemingly  being 
in  proportion  to  this  rise.     Htemoglobinuria  is  also  common. 

Classification. — The  classification  adopted  by  Morton  is  better, 
because  less  conqilex,  than  that  of  Dupuytren — viz.  First  degree : 
Hyperiemia,  erythema,  or  inflammation  of  the  skin  without  vesica- 
tion ;  no  scar  results.  Second  degree :  Inflanuiiation  of  skin  with 
vesication  ;  no  scar,  but  staining  possibly  from  pigmentation  follows. 
Third  degree  :  in  addition  to  all  seen  in  the  other  degrees,  destruction  of 
the  skin  and  subjacent  tissues  to  varying  degrees  up  to  complete  charring 
of  the  parts  ;  much  of  the  subsequent  scarring  and  deformity  results 
not  from  the  primary  injurs-,  l)ut  from  the  consecutive  sloughing  or 
gangrene. 

Symptoms. — BuRXS  of  First  Degree. — Local  Symptoms. — The 
diffused  redness  disappears  upon  pressure,  instantly  to  return.  Swelling 
sometimes  occurs,  and  the  pain  is  burning  or  smarting.  Lasting  from  a 
few  hours  to  some  days,  these  symptoms  decline,  cjiidermic  desquamation 
then  occurring. 

Constitutional  Sj/mptoms. — While  unusual,  slight  fever  may  develop, 
but  in  certain  patients  and  from  the  extent  of  surface  involved  shock  is 
pronounced,  and  even  death  may  result.  This  almost  certainly  occurs 
if  two-thirds  of  the  skin  is  merely  reddened.  Cerebral,  pulmonary, 
gastro-intestiual,  anit  even  vesital  complications  have  been  reported. 

Burns  of  the  Second  Degree. — Local  Si/mptoms. — The  inflamma- 
tion goes  on  to  separation  of  the  e]iidermis  from  the  derm  by  serum,  form- 
ing vesicles  or  Itulhc.  If  these  foi-m  very  rapidly,  the  epidermis  may  ru]»- 
ture,  leaving  collapsed,  wrinkle<l,  whitish  pellicles,  through  which  here 
and  there  can  be  seen  the  inflamed  hypersensitive  derm.  If  suppuration 
and  idceration  do  not  occur — /.  c.  if  infection  is  prevented — tlic  e])i- 
dermis  is  re-formed  in  a  week  or  two,  possibly  leaving  some  pigmen- 
tation. 


364       SYMPTOMS  AND   TREATMENT  OF  BURNS  AND  SCALDS. 

Consfitational  iSi/mjdoms. — Wlicn  involviiifr  a  limited  area  only  sligjlit 
eifects  result,  but  wlien  coverinii-  mueli  sui'face  tlie  shock  is  severe,  often 
promptly  terminating  in  death  with  delirium  and  coma  or  sym])toms  of 
congestion  of  the  lungs  or  other  viscera.  If  reaction  takes  ])iace,  visr 
ceral  congestions  may  terminate  in  visceral  inflammations.  Still  later, 
albuminuria  is  common  and  intestinal  ulceration  occasional. 

Burns  of  the  Third  Degree. — Local  I'^i/mptoms. — It  is  impossible 
immediately  to  determine  by  inspection  how  deeply  the  tissues  are 
destroyed,  as  the  surface  indications  are  very  similar  "  when  the  muscles 
or  the  deeper  parts,  even  the  bones,  have  been  involved."  Moreover, 
much  of  the  subsequent  destruction  results  from  the  sloughing  and  gan- 
grene from  septic  inflanunation.  It  is  therefore  useless  to  attempt  to 
describe  the  endless  differences  in  appearance  presented  by  this  class  of 
burns.  Sometimes  fingers,  toes,  parts  of  hands,  or  feet  may  be  burnt 
off.  Molten  metal  poured  into  a  puddler's  boot  will  produce  such  an 
injury. 

Constitutional  Symptoms. — If  reaction  takes  place,  death  from  cerebral 
coma,  caused  by  serous  effusion,  sometimes  occurs.  Congestions  followed 
by  inflammations  of  lungs,  kidneys,  or  intestines  may  result  fatally. 
Pyasmia,  septicemia,  exhaustion  aggravated  by  hemorrhages,  tetanus, 
one  or  all,  may  cause  death  during  the  process  of  separation  of  the 
sloughs  or  subsequently.  High  temperature  Avith  renal  trouble  is 
common. 

Prognosis  of  Btirns. — This  depends  on  many  circumstances.  Asep- 
tic and  antisejitic  methods  have  so  diminished  the  death-rate  that  the 
old  statements  as  to  the  mortality  of  an  injury  of  given  extent  and 
depth  must  be  modified.  Young  children  and  those  suflering  from 
shock  may  be  severely  burnt  or  scalded  by  comparati\-ely  low  tempera- 
tures, the  injury  at  first  appearing  trivial,  but  soon  extending  to  the 
deeper  parts.  Old  drunkards,  those  with  renal  or  hepatic  disease,  often 
succumb  when  those  with  healthy  organs  would  recover.  Laryngitis 
with  oedema  glottidis  places  patients  in  great  peril.  Delirium  due  to 
changes  in  the  l>lood-supply  of  the  cerebral  cortex  has  been  observed  : 
this  is  explainable  by  the  reflex  effects  produced  upon  the  vasomotor  sys- 
tem or  by  thrombosis  produced  by  disintegrated  red  corpuscles. 

Treatment. — First  relieve  pain  and  treat  the  shock.  "Where  mere 
erythema  exists,  unless  much  surface  is  involved,  only  local  treatment 
is  requisite,  dressings  such  as  will  exclude  the  air  or  will  neutralize  the 
acidity  of  the  secretions  being  indicated.  Oil,  fresh  lard,  or  cosmoline, 
previously  sterilized  by  heating,  best  fulfil  the  first  indication,  while  a 
paste  of  bicarbonate  of  soda  made  with  sterilized  water  will  meet  the 
second.  In  burns  of  the  second  and  third  degree,  if  much  surface  is 
damaged,  two  courses  are  open — viz.  a  preliminary  thorough  disinfec- 
tion with  a  weak  mercuric-bichloride  solution,  followed  by  a  moist 
dressing  impregnated  with  some  non-poisonous  germicide,  as  boro- 
salicylic  solution  or  hydronaphthol,  the  whole  covered  with  oiled  silk  ;  or, 
after  the  preliminary  cleansing,  all  injured  parts  must  be  carefully 
covered  with  protective,  outside  which  a  wet  sublimate  or  other  poison- 
ous germicide  may  be  safely  applied,  with  abundance  of  cotton  externally. 
When  such  a  dressing  requires  changing — which  should  only  be  done 
at  as  long  intervals  as  possible — any  cleansing  needed  can  be  effected  by 


BURNS  AND  SCALDS.  3G5 

sterilized  watei'  or  some  non-poisonous,  non-irritating  antiseptic  solntion. 
Irritating  and  readily-absorbed  poisonous  substances,  lilie  carbolic  acid 
and  corrosive  sublimate,  should  be  esciiewed  if  possible,  and  never  kept 
in  contact  with  large  surfaces,  lest  constitutional  effects  result.  The 
constant  warm  sterilized-water  bath,  when  feasible,  or  antiseptic  irriga- 
tion, is  useful  where  much  sloughing  results,  but  is  only  apjjlicablc  to 
extremities,  and  is  not  easy  to  manage  effectively  :  moreover,  absorption 
of  poisonous  substances  readily  occurs  during  irrigation  or  baths,  and 
must  be  carefully  guarded   against. 

After  separation  of  the  sloughs  healing  of  the  granulating  surface 
must  be  promoted,  upon  general  principles.  The  granulations  are  apt 
to  become  either  congested  and  fungous,  bleeding  readily,  or  (edematous. 
For  the  former  condition  soothing  and  slightly  astringent  ajiplications, 
such  as  sterilized  zinc-oxide  ointment,  nnist  be  used  ;  for  the  latter  moist 
dressings  should  be,  as  a  rule,  avoided  :  astringent  and  stimulating  dress- 
ings,  as  resin  cerate,  a])])lications  of  solution  of  zinc  sulphate  (grs.  j-x  to 
f  SJ)  or  of  copper  sulphate  in  similar  pi'oportions  with  each  dressing,  with 
the  occasional  use  of  solid  nitrate  of  silver  to  tlie  margins,  are  about  the 
best.  Chloral  hydrate,  grs.  x  to  f  gj  aquiB,  applied  by  means  of  lint  cov- 
ered with  oiled  silk,  will  often  act  admirably,  but  is  apt  to  produce  a  con- 
gested, fungous  state  (if  the  granulati<:)ns  if  employed  too  long.  It 
must  be  remembered  that  unless  the  whole  thickness  of  the  skin  be 
destroyed  the  epithelium  around  the  liair-  and  sebaceous  follicles  will 
proliferate,  thus  accounting  for  the  epidermic  islets  appearing  in  the 
midst  of  tlie  granulating  surfaces  left  after  burns.  These  centres  of 
cicatrizati(jn  must  be  carefully  conserved.  Skin-grafting,  preferably  by 
Tliiersch's  method,  and  plastic  operations,  are  often  requisite  to  secure 
healing.  Tiie  deformities  resulting  from  cicatricial  contraction  may  to 
a  certain  extent  be  ob\'iated  by  positi(jn,  s[)lints,  etc.  employed  during 
the  healing  process,  but  when  much  skin  and  fascia  have  been  destroyed 
some  plastic  procedure  will  become  requisite.  Such  operations  are  in- 
advisable until  all  tendency  to  contraction  has  ceased — /.  <;.  usually  in 
from  six  to  nine  months — unless  the  lower  jaw  is  becoming  curved  down- 
Avard  by  the  traction  in  the  very  young,  when  periiaps  some  operative 
interference  may  bo  warranted  earlier. 

SuxBtJRX. — While  usually  only  annoying,  causuig  much  burning 
pain,  wiien  a  great  extent  of  surface,  as  two-tiiirds,  is  involved,  death 
has  resulted  from  the  severe  dermatitis  and  subsequent  gangrene.  Exten- 
sive vesication  is  conunon.  Erysipelas  is  closely  simulated  at  times 
when  the  face  and  eyelids  are  involved,  but  there  is  no  febrile  disturb- 
ance.' 

Treatment. — It  is  that  of  a  burn  of  the  first  degree. 

Brush  Burn. — This  variety  of  contused  wound  is  caused  by  rapid 
friction,  as  that  produced  by  the  revoK'ing  leather  belts  of  machinery  or 
tile  dragging  of  a  i)atient  oxev  the  roadbed  by  a  train  of  cars  or  by  a  run- 
away team.  This  painful  condition  may  vary  from  a  superficial  abrasion 
to  complete  destruction  of  the  skin  and  undcrl}ing  tissues.  It  is  rarely 
extensive  enougli  to  be  dangerous. 

'  See  vol  ii.  p.  224,  Intrnxit.  Enci/.  of  Suir/.  Longstreth  here  reports  one  case  where  tlie 
muscles  and  synovial  teudinous  sheaths  of  the  forearm  and  wrist  became  secondarily 
involved. 


3C()        SYMPTOMS  AND   TREATMENT  OF   WOUNDS. 

Treatment. — This  is  identical  with  that  of  a  contused  wound  which 
sloughs. 

IjK;htnixg-.sti!OKE. — Wliile  it  is  true  that  the  passage  of  a  power- 
ful current  of  aerial  electricity  througji  the  human  frame  usually  results 
in  death,  tliis  is  not  invariable.  \\  liat  is  commonly  called  "struck  by 
lightning  "  means  that  air-indueed  electrical  shock  occurs  in  the  individ- 
ual when  some  contiguous  object,  as  a  tree  or  another  person,  receives 
the  direct  (>leetrical  discharge. 

Symptoms. — In  non-fatal  cases  the  phenomena  of  shock  are  jiro- 
nounced,  luicousciousness  or  coma  lasting  from  a  few  hours  to  daj'S. 
Im})airment  of  one  or  more  of  the  special  senses  is  common,  v.'ith  paresis 
or  paralysis  of  both  upper  and  lower  extremities.  Localized  aufesthesia 
is  quite  usual.  These  pareses  or  paralyses  are  usually  transitory,  except 
perhaps  that  of  vision.  Locally,  burns  of  varying  depths  are  not 
uncommon,  while  simple  or  compound  and  conuninuted  fractures,  and 
even  partial  or  comj)lete  avulsions  of  extremities,  have  been  reported. 
A  peculiar  arborescent  series  of  tracks,  characterized  bj-  slightly  cedema- 
tous,  raised,  bright-red  lines,  often  diverge  from  the  point  where  the 
current  entered.  Where  death  is  delayed  it  results  from  shock,  cerebral 
efiPusions — hemorrhagic  or  otherwise — or  hemorrhages  into  some  of  the 
great  cavities,  with  perha])s  rupture  of  some  of  the  contained  organs, 
or  the  severe  fractures  already  mentioned. 

Treatment. — This  must  be  conducted  upon  the  general  principles 
governing  the  treatment  of  shock,  burns,  or  paralysis  of  any  nerve  or 
nerves. 

Wounds. 

A  wound  is  a  solution  of  continuity  suddenly  effected  by  anything^ 
which  cuts  or  tears.  When  this  is  effected  without  division  of  the  skin, 
the  term  "subcutaneous"  is  employed,  the  injury  giving  rise  to  little  or 
no  constitutional  symptoms,  and  healing  taking  place  by  simple  adhesive 
inflammation. 

Wounds  are  usually  classed,  according  to  their  causation,  as  incised, 
when  resulting  from  a  sharp-edged  object ;  contused,  when  produced 
by  more  diffused  force,  which  divides  the  tissues,  leaving  the  woiuid- 
edges  bruised,  as  i'rom  the  blow  of  a  bludgeon  ;  laeei-ated,  when  irregu- 
larly torn,  as  by  the  bite  of  a  wild  beast,  entanglement  in  machinery, 
etc. ;  punctured,  when  the  depth  much  exceeds  the  superficial  area,  as 
bayonet,  knife,  and  sword  \vounds. 

Incased  Wounds. — Because  the  injury  cleanly  divides  the  tissues, 
not  dragging  on  or  tearing  contiguous  sensitive  parts,  the  pain  is  apt  to 
be  less  in  this  variety  of  wound.  The  bleeding  varies,  but  is  much 
freer  than  in  lacerated  or  contused  wounds.  Wounds  of  the  face  bleed 
very  freely  even  if  no  considerable  vessel  be  divided,  the  same  being 
true  of  the  seal]);  but  in  this  latter  situation  the  hemorrhage  occurs 
because  the  density  of  the  scalp-structui'es  interferes  with  the  contrac- 
tion and  retraction  of  the  vessels. 

Retraction  of  the  edges  of  incised  wounds  always  occurs,  dependent 
upon  the  position  and  subjacent  structures.  This  point  it  is  important  to 
remember,  because  if  incisions  are  properly  planned  few  sutures  will  be 
requisite,  and  these  will  be  efficient ;  thus  skin  and  fascial  wounds  made 


WOUNDS.  367 

transverselv  to  the  course  of  underlying  muscular  fitjrcs  will  gape  widely, 
but  if  made  parallel  to  the  muscle  their  edges  will  either  remain  in  contact 
or  require  but  little  artificial  aid  in  maintaining  this  position.  "  Langer's 
investigations  into  the  direction  in  which  the  skin  splits  show  that  the 
tension  of  the  skin  varies  greatly  in  two  different  directions  :  two  incisions 
vertical  to  each  other  exliibit  a  varying  retraction  of  the  wound-margins  ; 
Avhile  one  gapes  widely,  the  edges  of  the  other  remain  in  contact  even 
without  artificial  means."  .  .  .  .  "  Fortunately,  the  course  of  the  nerves 
and  vessels  largely  coincides  with  the  direction  in  which  the  skin  shows 
the  greater  tension."  '  Skin  and  muscle  gape  most  widely  when  divided, 
the  one  across  the  line  of  cleavage,  the  otlicr  at  right  angles  to  its  fibres. 
Gaping  is  greater  when  there  is  much  inHainmatory  tension  of  the  sub- 
jacent parts. 

Union  of  Incised  Wounds. — The  hemorrhage  having  been  arrested, 
the  wound,  accurately  closeil,  drained  if  necessary,  kept  aseptic  and  at 
rest,  unites  without  supjniration  by  simple  adhesive  inflammation.  If 
the  epithelial  covering  be  thin,  the  edges  may  occasionally  present  for  the 
first  twenty-four  to  seventy-two  hours  a  faint  blush,  Init  this  is  often  absent. 
They  are  ])erhaps  slightly  swelled,  are  hotter  and  tender  on  pressure,  but 
are  devoicl  of  pain  :  sometimes  all  these  symptoms  are  absent.  Even  at 
the  end  of  three  days,  although  the  union  seems  firm,  the  wound-edges 
can  be  pulled  apart — the  union  is  mechanical,  not  vital,  resulting  from 
the  gluing  together  of  parts  Ijy  cellular  exudate  and  fibrin.  If  undis- 
turbed, in  a  few  more  days  a  narrow  reddened  -streak  indicates  the 
position  of  the  former  cut,  the  color  fading  in  time  into  white  until 
the  scar  almost  disappears.  This  process  is  primary  union,  or  "  union 
by  first  intention,"  and  an  attempt  to  secure  it  should  always  be 
made.  If  perfect  coaptation,  drainage,  and  asepticism  be  impossible, 
the  faintl}'-reddened  margins  soon  show  a  decided  inflammatory  blush ; 
the  edges  become  swollen  and  tense,  throbbing  pain  is  complained  of, 
union  fails  to  occur,  and  pus  forms.  A  chill  or  rigor  may  occur,  and 
headache,  fever,  anorexia,  coated  tongue,  constipation,  scanty  high- 
colored  urine,  with  nervous  symptoms  varying  from  mere  restlessness 
to  slight  delirium,  indicate  that  septic  traumatic  fever  has  supervened. 
If,  now,  effective  drainage  and  antisepsis  be  instituted,  all  the  symji- 
toms  will  decline:  granulations  form;  the  wound-margins  ai'c  no  longer 
elevated,  but  rather  depressed ;  the  masses  of  granulations  level  the 
inequalities  of  the  depths  of  the  wound ;  the  deeper  layers  become 
convertetl  into  young  connective  tissue,  which  contracts,  thus  lessening 
the  superficial  area  of  the  \\ound ;  epithelial  cells  extend  inwai'd  from 
the  margins  until  cicatrization  is  completed,  first  a  red,  and  finally  a 
white,  scar  remaining.  This  process  constitutes  healing  by  granulations, 
or  "  healing  by  second  intention." 

In  brief,  the  process  of  repair  l>y  primary  union  is  as  follows  :  A 
small  quantity  of  exudate,  containing  fibrin-forming  constituents,  coagu- 
lates, temporarily  gluing  together  all  surfaces  which  arc  in  apposition, 
the  excess  of  exudate,  if  any,  being  drained  off.  Leucocytes  collect 
along  the  line  of  the  wound,  gradually  increasing  in  numbers  until 
many  of  the  original  tissue-elements  disappear,  leaving  only  a  mass  of 
so-called  "  indifferent  cells  "  lying  in  the  meshes  of  a  granular  or  fibril- 

'  Kocher's  Operative  Surf/ery,  1894,  p.  29. 


368        SYMPTOMS  AND   TREATMENT  OF   WOUNDS. 

lated  reticular  intercellular  substance.  At  first  these  cells  receive  nutri- 
ment indirectly  from  the  lilood-vessels  through  the  plasma-eanais  de- 
scribetl  by  Thiersch,  whicli  are  themselves  in  direct  connnunication 
with  the  blood-vessels.  While  granulation  tissue  contains  leucocytes, 
the  weight  of  evidence  favors  the  view  that  the  cells  of  granulation 
tissue  result  from  the  iiroliferation  of  the  fixed  connective-tissue  cells 
and  possibly  those  of  the  parencliyma  of  organs,  the  leucocytes  serving 
as  food  for  these  cells.  Soon  capillary  loops  develop  from  pre-existing 
blood-vessels,  penetrate  the  masses  of  cells,  and  pass  across  from  one 
side  of  the  wound  to  the  other.  Pari  passu  with  this  spindle-eells  develop 
from  the  round-cells.  Most  of  these  spindle  cells,  in  turn,  disappear  as 
the  new  fibrous  tissue  forms,  either  by  conversion  into  this  or  by  granular 
degeneration  and  absorj)tion.  On  the  surface  of  the  wound  new  epithelial 
cells  are  formed  from  the  deeper  layers  of  the  rete  mucosum,  sometimes 
under  a  scab  of  dried  blood  and  exudation-material,  beneath  which  the 
young  cells  remain  undisturbed  until  fully  developed,  when  this  portion 
of  the  process  is  essentially  what  has  been  termed  "  healing  under  a 
scab  "  or  "  by  scabbing." 

If  too  much  exudate,  serous  or  primarily  more  solid,  is  allo^ved  to 
accumulate  iu  a  wound,  the  mechanical  bond  effected  by  the  fibrin  is 
broken  down,  thus  delaying  union ;  if  excessive  congestion  occur, 
much  more  if  inflammation  results  from  any  cause,  this  mechanical 
disturbance  from  excess  of  exudate  is  probable.  It  also  favors  infec- 
tion and  interferes  witli  the  processes  of  repair.  The  same  processes 
occur  in  wounds  with  loss  of  substance  or  where  primary  coaptation 
has  been  neglected.  In  lacerated  and  contused  wounds  the  damaged 
tissues  must,  indeed,  be  first  removed,  which  is  effected — whether 
tliev  be  hard,  as  bone,  or  soft,  as  cellular  tissue — by  the  accumulation, 
at  the  junction  of  the  dead  and  living  tissues,  first  of  numerous  leu- 
cocytes, then  of  cells  gradually  forming  granulation  tissue,  substitut- 
ing the  tissues  at  such  points.  Finally,  the  intercellular  cement  or 
reticulum  of  the  boundary  layer  of  cells  dissolves,  loosening  the  slough, 
which  floats  away  in  the  liquid  exudate,  leaving  a  layer  of  healthy 
granulations  beneath.  When  situated  upon  a  free  sui-face  healthy 
granulations  present  a  level,  slightly  granular  surface,  whicli  does  not 
project  above  the  margins  of  the  wound  ;  they  are  of  a  pink  color,  a  small 
amount  of  creamy  pus  being  secreted  if  infection  has  occurred,  or  an 
opaque  serous  or  occasionally  viscid  fluid  in  aseptic  cases.  The  mar- 
gins are  smooth,  shelving,  uninflamed,  and  an  advancing  border  of 
bluish-white  new  epithelium  is  present. 

Healing  by  Second  Intention. — This  is  the  normal  method  where 
loss  of  substance  has  occurred  either  from  accident,  operation,  or  where 
gaping  results  from  failure  of  primary  union.  While  it  is  usually  stated 
that  the  wound  "  fills  up,"  the  fact  is  that,  although  this  occurs  to  a  lim- 
ited extent,  the  organization  of  the  deeper  portions  of  the  gramdations 
causes  a  marked  diminution  in  area  of  the  surface  and  a  drawing  down 
of  the  margins,  leaving  a  much  smaller  surface  to  be  covered  in  by  epi- 
dermis than  is  usually  supposed.  Upon  this  organization  into  scar- 
tissue  of  the  granulations,  and  tiicir  uninterrupted  subsequent  contrac- 
tion, depends  the  healing  of  many  ulcers.  Healing  by  granulation  is 
then  the  rule  in  contused  and  lacerated  wounds,  and  in  incised  wounds 


WOUNDS.  369 

whose  surfaces  cannot  be  coaptated  or  where  primary  union  lias  failed. 
AVheu  two  surfaces  covered  by  iieahhy  granuhxtions  are  held  in  contact, 
fusion  often  occurs ;  loops  of  blood-vessels  pass  from  one  side  to  the 
other,  fibre-cells  stretch  across,  and  the  wound  promptly  closes  by  seo- 
ondari/  (tdhcsion,  or  "  by  third  intention."  This  process  is  purposely 
utilized  in  certain  cases, "  secondary  suturing  "  being  employed  for  coap- 
tation. 

Treatment  of  Incised  Wounds. — First  arrest  the  hemorrhage,  then 
cleanse  the  jtarts  In-  a  gentle  stream  of  sterilized  or  antiseptic  water. 
Ne\er  distend  a  wound-cavity.  Remove  foreign  bodies  with  forceps ; 
do  not  rub  the  surfaces  with  a  sponge.  If  the  dry  method  of  operating 
be  jjreferred,  of  course  no  water  is  employed,  the  wound  being  cleansed 
with  pledgets  of  sterilized  gauze,  etc.  Where  the  wound  is  irregular 
and  deep,  especially  in  not  very  vascular  parts,  one  of  two  courses  must 
be  pursued — viz.  either  all  spaces  where  blood  and  serum  can  collect 
must  be  effaced  h\  buried  sutures,  or  some  means  must  be  provided  for 
the  free  escape  of  blood  first,  and  scrum  later ;  which  latter  is  exjjressed 
from  the  clots  or  exudes  from  the  irritated  surfaces  :  the  coagulable  mate- 
rial probably  contains  nucleins  enough  to  destroy  germs,  but  the  serum 
does  not. 

Drainage  is  not  usually  necessary  for  more  than  twenty-four  to  forty- 
eight  hours.  If,  however,  infection  has  occurred  and  disinfection  cannot 
be  assure<l,  drainage  is  certainly  indicated  until  the  dangers  of  sepsis  are 
passed.  When  only  blood  and  serum  need  removal,  capillary  drains  will 
suffice,  but  these  must  never  be  employed  for  pus,  tubes  being  here  relied 
upon.  A  capillary  drain  may  be  either  absorbable  or  non-absorbable, 
the  former  being  comjjosed  of  fine  catgut,  the  latter  of  sterilized  horse- 
hair. From  ten  to  twenty  or  more  strands  of  fine  gut  should  be  secured 
in  the  middle  by  a  single  ligature  threaded  on  a  needle,  whereby  the 
drain  is  sewed  to  the  deepest  portion  of  the  M'ound.  Between  the  buried 
sutures,  if  such  are  employed,  three  to  four  strands  are  brought  to  the 
cutaneous  surface.  Each  set  of  strands  is  now  included  between  two 
interrupted  sutures,  the  individual  threads  are  laid  carefully  parallel 
and  in  contact,  and  the  ends  cut  off  square  about  an  inch  beyond  the 
margins  of  the  wound.  To  prevent  drying,  and  thus  converting  the 
strands  into  narrow  tapes  which  will  not  drain,  the  protective  must 
extend  some  distance  beyond  the  ends  of  the  drains.  Employed  in 
this  manner,  amputation  or  other  large  wounds  can  be  readily  drained. 
When  tubes  are  used,  they  must  only  reach  into  the  cavity  to  be  drained, 
and  he  cut  flush  with  the  surface  ;  must  be  there  secured  by  a  stitch  or 
Siifety-pin ;  had  better — as  in  amputations  of  the  breast — be  brought 
out  through  a  special  incision  at  the  most  dependent  portion ;  must 
be  of  glass  if  likely  to  be  kinked  or  flattened  by  pressure ;  and  must 
be  removed  at  the  earliest  possible  moment.  When  used  for  pus- 
cavities  they  must  be  gradually  shortened.  For  superficial  wounds, 
especially  in  vascular  parts,  for  absolutely  aseptic  wounds,  and 
where  by  buried  suture  all  spaces  are  effaced,  they  are  umiecessary 
and  injurious.  Some  surgeons  employ  both  tube  and  capillary 
drainage,  removing  the  first  within  twenty-four  hours  and  leaving 
the  absorbable  drain,  or,  if  horse-hair  be  employed,  pulling  out  a 
few  hairs  at  a  time  during  subsequent  dressings.     Placing  the  parts 

Vol.  1.-2.1 


370  SYMPTOMS  AND   TREATMENT  OF   WOUNDS. 

at  iK'i't'cct  rest,  as  on  »  .splint,  compresses,  and  gentle  but  firm 
banclajjing  will  aid  in  doing  away  with  drainage  by  securing  prompt 
union  of  the  dee])  as  well  as  of  the  sujierficial  parts.  Aseptic  or 
antiseptic  dressings  in  amount  proportioned  to  the  probable  extent 
of  oozing  must  be  applied. 

The  closure  of  incised  wounds  may  be  effected  by  sutures,  which 
may  be  interrupted  or  continuous.  The  ideal  method  of  suturing  is  to 
unite,  by  buried  sutures,  muscle  to  nuisele,  fascia  to  fascia,  and  skin  to 
skin,  neither  inverting  nor  everting  the  latter.  Buried  sutures  of  the 
skin,  passing  the  stitciies  so  as  to  include  merely  the  dense  corium,  but 
not  tlic  epithelium,  are  preferred  by  many  surgeons  because  of  lessened 
chances  of  stitch-abscesses  resulting  from  infection  by  germs  resident 
in  or  upon  the  skin,  and  the  avoidance  of  the  scars  lelt  by  the  punc- 
tures. 

Coaptating  sutures  must  never  be  drawn  too  tight,  lest  they  imperil 
the  vitality  of  the  included  tissues,  thus  favoring  sujipu ration.  In  a 
thoroughly  aseptic  ^\•ound  any  pliable  aseptic  material  will  serve  for 
sutures,  as  silk,  silkworm-gut,  catgut,  kangaroo  or  dog-tail  tendon, 
but  non-absorbable  substances  may  at  any  future  time  give  rise  to 
trouble,  so  that  where  kangaroo  or  other  tendon  has  sufficient  .stability 
for  the  purpose  it  shoukl  be  employed,  and  next  to  this  Cliinese  twist 
silk.  Needles  may  be  straight,  curved,  or  jiartially  curved,  according  to 
whether  the  woimd  be  in  a  free  surface  or  a  concave  or  convex  one,  and 
should  never  l)e  larger  tlian  requisite  to  carry  the  thread.  The  Hagedorn 
needle  is  coming  into  vogue,  and  serves  a  good  purpose  in  many  situ- 
ations, but  often  makes  too  large  a  wound.  A  round  sewing-needle  is 
best  for  all  operations  on  the  bowels,  bladder,  or  peritoneum.  Sutures 
may,  in  certain  localities — as,  for  instance,  the  scalp — be  substituted  by 
strips  of  gauze  fixed  first  on  one  side  of  the  wound  by  collodion  ;  the 
lips  are  to  be  approximated  by  traction  on  the  strip,  which  nuist  then  be 
secured  on  the  opposite  side  by  more  collodion.  After  removal  of  sutures 
the  same  means  can  be  employed  to  su])port  the\\'Ound.  Adhesive  straps 
should  never  be  used  to  draw  a  wound  together,  but  may  be  employed 
to  take  strain  off  the  stitches  or  to  support  the  recent  scar  Ijy  interposing 
several  layers  of  antise])tic  or  aseptic  gauze.  Antiseptic  compresses  and 
proper  bandages,  exercising  pressure  through  layers  of  elastic  materials, 
such  as  cotton,  oakum,  etc.,  sometimes  serve  as  suecedanea  to  suturing  by 
maintaining  quiet  of  the  deeper  parts,  promoting  drainage,  and  relieving 
strain  upon  the  stitches. 

Essentials  requisite  for  good  wound-dressings  are  tliat  they  shall  be 
absorbent — /.  e.  favor  drying,  which  interferes  with  germ-growth — and 
that  they  shall  contain  germicidal  substances,  preventing  infection  of  the 
discharges,  which  in  turn  may  reach  the  wound  :  both  of  these  properties 
render  frequent  dressing  unnecessary,  thus  giving  rest  to  the  wound. 
Sterilized  iodoform  promotes  drying  of  the  secretions,  and,  if  sepsis  occurs, 
will  hel]i  to  destroy  the  resultant  ptomaines.  One  indication  for  chang- 
ing the  dressings  will  be  their  penetration  by  the  discharges,  but  if  the 
discharge  is  slight  and  jirompt  drying  occurs  at  the  margins  of  the  stained 
area,  a  pad  of  fresh  antiseptic  gauze  may  be  secured  over  that  part  if  it  be 
undesirable  to  uncover  the  wound.  Again,  if  the  temperature  indicates 
ti'ouble  which  is  not  exjjlainable  by  complications  located  elsewhere,  the 


WOUNDS.  371 

wound  must  be  inspected,  lest  drainage  be  defective  or  infection  may  have 
occurred. 

Constitutional  Treatment. — During  the  first  few  days  simple,  easily- 
digestible  liquid  or  soft  diet  is  indicated,  after  which,  if  the  bowels  act 
normally,  fever  being  absent,  ordinary  full  diet  may  be  given  should  the 
patient  desire  it.  If  loss  of  blood  or  2:)revious  drain  of  pus  has  occurred, 
forced  alimentation  may  be  requisite,  with  stinudants,  as  alcohol  in  some 
form,  and  such  drugs  as  ammonia,  strychnia,  digitalis,  (juinine,  etc. 
^\'atch  must  be  kept  that  tlic  bladder  is  properly  emptied — that  tlie 
renal  and  alvine  secretions  are  normal  in  character  and  quantity.  Proper 
sleep  must  be  secured,  especially  for  the  young  and  the  old. 

Treatment  of  Lacerated  and  Contused  "Wounds. — As  some  con- 
tusion is  present  in  most  lacerated  wounds,  the  treatment  of  both 
varieties  will  be  considered  together. 

The  cleansing  and  rendering  tlicse  wounds  thoroughly  aseptic  is  a 
most  difficult  task,  which  is  too  often  but  partially  done  :  still,  every 
reasonable  etfort  must  be  made.  Tube-drainage  must  be  employed  unless 
the  wound  lie  so  shaped  and  situated  that  it  will  drain  itself.  The  ap- 
parently hojiclcssly  tlamagcd  tissues  may  be  removed,  except  about  the 
face,  mouth,  and  scalp,  where  the  vascularity  is  such  that  nothing  had 
better  be  removed.  Possibly  slight  trimming  of  the  margins  of  a  face- 
wound  in  order  to  secure  primary  union  may  be  permissible,  but  unaided 
nature  will  here  do  marvels,  and  subsequent  defonuity  may  later  be  re- 
moved by  operation.  Sutures  are  rarely  advisable  or  necessary,  except 
in  the  face,  where  their  judicious  use  will  often  secure  a  good  result.  Rest 
to  the  part,  with  a  voluminous  dressing,  outside  of  M'hich  dry  cold  may 
be  applied,  is  often  useful,  lessening  the  severity  of  the  inflammation 
and  consequent  sloughing.  \yith  extensively  contused  wounds  cold 
must  be  cautiously  employed,  lest  the  sloughing  be  increased.  Where 
contusion  is  the  chief  feature  but  little  primary  hemorrhage  occurs,  as 
is  also  true  of  lacerated  wounds,  but  much  blood  is  cxtravasated  in  the 
tissues.  This  interferes  with  the  circulation  in  the  tissues  ;  hence  slough- 
ing is  more  apt  to  be  extensive  than  in  lacerated  wounds,  so  that  second- 
ary hemorrhage,  when  the  sloughs  separate,  is  an  accident  to  be  dreaded. 
Suppuration  and  destruction  of  tissue  by  sloughing  are  apt  to  occur  in 
both  classes  of  wounds,  despite  all  eiForts  to  secure  antisepsis.  Such 
complications  as  spreading  cellulitis  or  gangrene,  or  any  variety  of  sepsis 
or  infection,  arc  all  possible.  Extensive  scarring  especially  follows  con- 
tused wounds.  When  feasible,  if  spreading  cellulitis  with  free  suppu- 
ration occurs,  antiseptic  irrigation  or  the  continuous  bath — warm  or  cold 
according  to  the  condition  as  to  sloughing,  etc. — is  often  better  than  an 
ordinary  closed  dressing. 

Punctured  Wounds. — Th^  dcptli  of  tliese  wounds  is  greater  than 
their  width.  Tiiey  are  produced  l)v  pointed  objects,  as  knives,  bayonets, 
swords,  nails,  umlirella-sticks  and  walking-canes,  splinters  of  wood, 
stakes,  etc.  The  dangers  of  these  wounds  are — hemorrhage  from  deep 
vessels,  damage  to  important  nerves,  penetration  of  cavities,  and  deep, 
widespreading  suppuration.  When  inflit^ted  by  a  sharp  uninfected  instru- 
ment, as  a  trocar,  they  pursue  a  course  similar  to  other  wounds,  but  when 
resulting  from  a  rough  object,  such  as  a  board-nail,  the  end  of  a  stake,  a 
cane-ferule,  and  like  objects,  the  results  differ,  because  often  fragments 


372  SYMPTOMS  AND   TREATMENT  OF   WOUNDS. 

of  clothing,  the  inner  sole  of  a  shoe,  or  fragments  of  the  more  superficial 
tissues-are  torn  oH'and  deposited  in  the  dejiths  of  the  wound.  It  is  this 
fact,  rather  than  l)ccause  the  various  planes  of  tissue  change  their  i-ela- 
tions  after  the  wound  has  been  inflicted  so  that  exudates  cannot  escape, 
which  exj)lains  the  gravity  of  punctured  woimds.  Hence  for  therapeutic 
purposes  punctured  M'ounds  must  be  divided,  as  Van  Buren  teaches,  into 
the  smooth  and  the  rough. 

Treatment. — Hemorrhage  having  been  arrested  and  asepsis  secured 
and  maintained,  nothing  beyond  securing  rest  to  the  jjarts  by  splint 
or  position  is  requisite  for  the  smooth  variety.  If  infection  has  oc- 
curred, symptoms  of  deep  eellulitis  or  of  pleuritis  or  peritonitis  will 
develop,  according  to  the  parts  involved,  in  which  case  the  therapeutics 
of  these  conditions  are  indicated.  Kough  punctures,  where  foreign  bodies 
or  fragments  of  dead  tissues  may  be  present  to  act  as  infected  foreign 
bodies,  must  be  treated  by  effectual  disinfection,  a  drainage-tube  intro- 
duced to  the  bottom  of  the  wound,  absolute  rest  of  the  part,  perhaps  sup- 
plemented by  primary  counter-openings,  and  ceiiainly  by  a  sufficient 
number  of  these  later  on  if  deep  suppuration  occurs. 

Poisoned  Wounds. — These  are  treated  of  in  the  chapter  on  "  Sep- 
tica?mia,  Pynemia,  and  Poisoned  Wounds,"  by  Dr.  Carmalt,  and  will  be 
but  briefly  referred  to  here.  Formerly,  when  no  preservatives  were  em- 
ploj-ed  in  the  preparation  of  bodies  for  dissection,  so-called  dissection- 
wounds  were  common  and  serious.  At  present  post-mortem  examinations 
of  bodies  recently  dead  from  infective  diseases  are  practically  the  only 
source  for  these  wounds.  For  a  short  time  after  death  the  infective 
micro-organisms  can  maintain  their  virulence,  but  the  bacteria  of  putre- 
faction soon  replace  them,  after  which  only  local  inflammation  can  result 
from  wounds  contaminated  during  post-mortem  examinations.  The 
bodies  of  those  dying  of  septicemia,  pyaemia,  septic  peritonitis,  or  of 
erysipelas  have  i)roved  the  most  dangerous.  Those  in  vigorous  health 
and  in  the  habit  of  performing  post-mortem  examinations  are  rarely 
afl'ected — /.  e.  they  have  an  acquired  immunity  from  frequent  exposure. 

Symptoms. — These  vary  with  the  previous  health  and  the  poison. 
Sometimes  a  pustule  forms,  ruptures,  scabs  over  temporarily,  and  a  pain- 
ful inflamed  ulcer  forms,  persisting  for  months ;  again,  a  ■\\'art-like  mass 
forms,  both  conditions  being  often  tubercular.  A  combination  of  local 
and  systemic  infection  is  more  common,  where  the  piuncture  or  wound 
becomes  inflamed  and  suppurates ;  the  superficial  or  deep  lymjihatic 
vessels,  or  both  sets,  become  involved ;  the  lymphatic  glands  enlarge 
and  often  suppurate ;  while  early  in  the  case  a  sharp  rigor,  followed  by 
fevei*,  and  perhaps  sweating,  is  common.  Some  cases  belonging  to  this 
class  have  a  repetition  of  rigors  ;  a  typhoid  state  is  early  developed,  with 
multiple  glandular  suppuration,  and  purulent  peri-adenitis  involving  the 
axilla,  neck,  and  side  of  the  thorax.  In  some  of  the  more  serious  cases 
neither  distinct  local  sym])toms  nor  involvement  of  the  lymphatic  ves- 
sels precede  the  onset  of  the  constitutional  symptoms  and  the  axillary 
adenitis,  etc. 

The  prognosis  in  this  last  class  of  cases  is  bad,  death  often  taking  place 
in  from  a  few  days  to  three  or  four  weeks.  More  rarely  recovery  ensues, 
leaving  an  impaired  constitution  for  long  periods  or  for  life. 

Treatment. — When  the  injury  is  recognized  at  the  time,  encourage 


WOUNDS.  373 

fi'ee  bleeding,  cleanse  carefully  hy  prompt  soaking  of  the  part  in  the 
most  reliable  germicidal  solution  attainable,  followed  by  a  moist  anti- 
septic dressing.  Sores  and  warts  must  be  destroyed  by  caustics  or  curet- 
ting, or  both.  The  brawny  indurations  of  cellulitis  must  be  freely  incised, 
pus-pockets  be  opened  and  drained,  and  sloughs  be  allowed  exit.  Measures 
adapted  to  the  maintenance  of  the  patient's  strength  must  be  used,  such 
as  stimulants  and  good,  easily-digestible  food.  Cardiac  stimulants — 
strychnia,  quinine,  and  digitalis — arc  invaluable.  Sleep  must  be  secured 
and  the  eliminating  powers  of  the  skin,  bowels,  and  kidneys  called  uj)on. 

Contusions. — These  are  subcutaneous  lacerations,  the  skin  surtiuie 
remaining  unbroken.  They  are  caused  by  blows  with  hard,  blunt 
objects  or  by  violent  compression.  The  connective  tissue  with  its 
vessels  suffers  most,  but  muscles,  veins,  arteries,  and  lymphatics  may 
all  be  lacerated,  the  nerves  escaping  as  a  rule.  Every  grade,  from  a 
slight  bruise  to  a  pulpefication  of  the  part,  may  occur.  In  the  slighter 
grades  a  few  vessels  are  ruptured,  producing  swelling  and  discoloration 
of  the  parts.  In  other  instances,  where  the  tissues  are  lax  or  the  injury 
is  severe,  as  in  a  crush  of  a  limb,  the  major  part  of  the  skin  may  be 
stripjx'd  oft"  from  the  deep  fascia  and  tlie  internuiscular  spaces  be  dis- 
tended by  such  an  enormous  extravasation  that  death  results  from  the 
sudden  abstraction  of  blood  from  the  circulation. 

When  a  blood-collection  becomes  circumscribed  by  condensation  of 
the  surrounding  tissue,  it  is  called  a  hasmatoma,  in  certain  regions,  as  the 
scalp,  receiving  a  prefix,  as  ccphal-hrematoma.  When  the  pressure  of 
the  extravasation  prevents  furtlicr  effusion  of  blood,  this  usually  clots, 
later  breaking  down  into  a  thick  reddish  fluid.'  Absorption  is  the  rule 
unless  the  tissues  have  their  nutrition  seriously  impaired,  the  extravasa- 
tion be  large,  or  in  predispomng  conditions  infection  occurs,  when  sup- 
puration will  take  place.  When  the  pressure  is  great,  so  that  the  nutri- 
tion of  the  skin  stripped  from  the  subjacent  tissues  is  much  impaired, 
blebs  form  through  which  infection  occurs,  or  the  germs  may  reach  this 
locus  minoris  rcsistcntiic  through  the  circulation.  In  certain  localities 
pus  forms  more  readily  than  in  othei's,  as  in  the  thoracic  and  abdominal 
walls.     Cephalhiematoma  in  infants  never  appears  to  suppurate. 

The  irritated  tissues  son^etimes  develop  a  layer  of  granulation  tissue 
around  the  effusion,  which  may  be  converted  into  fibrous  tissue,  or  in 
some  cephalhfematomata  into  bone.  The  central  liquid  portion  becomes 
decolorized,  and  if  surrounded  by  a  sac  of  fibrous  tissue  a  serous  cyst 
is  formed.  This  may  remain  unchanged,  or,  the  fluid  contents  being 
finally  absoi'bed,  a  dense  mass  is  left,  which  in  time  perhaps  undergoes 
absorption. 

Symptoms. — The  pain,  unless  a  nerve-truidv  is  involved,  is  depend- 
ent upon  the  tension.  This,  in  turn,  is  due  to  swelling,  which  varies 
with  the  amount  of  blood  eflused  and  tlie  laxity  of  the  tissues.  The 
discoloration  promptly  appears  if  the  bruise  be  superficial,  but  may  not 
be  shown  until  many  days  have  passed  if  only  the  deeper  parts  are 
involved  or  the  extravasation  occurs  beneath  a  dense  fascia.  First  dark 
purple,  the  color  changes  to  green,  then  to  yellow,  finally  fading  out.  If 
a  large  vessel  be  concerned,  the  loss  of  blood  may  be  very  dangerous, 
if  not  fatal,  as  in  a  case  of  my  own  where  the  external  iliac  vein  with 
'  Moullin  states  that  this  changes  to  a  lighter  hue  when  exposed  to  the  air. 


374      SYMPTOMS  AND   TREATMENT  OF  TRAUMATIC  DELIRIUM. 

tlic  (k'L'p  circumflex  arterv  was  turn.  The  extravasation  occupied  the 
whole  lower  extremity,  ancl  formed  an  enormous  subperitoneal  lueniatoma. 
Fever  is  usually  in  proportion  to  the  extravasation  and  laceration  of 
tissues — /.  €.  the  amount  of  fibrin-ferment  and  nucleins  absorbed.  When 
near  the  surface  the  overlyiufi'  skin  presents  the  evidences  of  a  plastic 
inflammation,  which  soon  disappears  unless  infection  causes  suppuration. 
Treatment. — Rest  for  the  part,  and  spirit  and  water  or  diluted  lead- 
water  lotions  so  applied  as  to  permit  constant  evaporation  taking  place, 
serve  best  for  the  more  superficial  varieties.  In  the  more  severe  cases 
gentle  elastic  pressure,  effected  l)y  bandages  applied  over  a  thick  layer 
of  cotton-wool,  after  having  emj)tied  all  blebs  and  protected  them  anti- 
scptically,  often  checks  the  ett'usic)n  and  promotes  absorption.  Because 
in  severe  contusions  portions  of  the  skin  may  have  been  killed,  light 
antiseptic  dressing  must  always  be  ajiplied  to  obviate  accidental  infection. 
Where  the  tension  compromises  the  integrity  of  the  parts  or  suppuration 
seems  imminent,  aseptic  aspiration,  followed  by  pressure,  is  indicated. 
When  the  collateral  circulation  is  seriously  interfered  with,  as  the  blood 
])robabIy  comes  from  a  large  vessel  or  vessels,  incision,  ligatures,  antl 
proper  drainage  and  asepsis  are  indicated. 

Traumatic  Delibium. 

This,  which  sometimes  follows  certain  injuries  or  operations,  results 
from  several  distinct  conditions.  Thus  it  is  a  symptom  of  septic  trau- 
matic fever,  when  it  usually  l)ecomes  pronounced  during  the  height  of 
this — viz.  from  the  second  to  the  fifth  day — subsiding  with  the  fever 
producing  it.  It  is  most  marked  at  night,  and  is  usually  in  pro])ortion 
to  the  pulse  and  temperature. 

Prognosis. — This  is  favorable  if  the  cause  is  removable,  as  is  usually 
the  case. 

Treatment. — Disinfection  and  drainage  of  the  wound,  with  cold  to 
the  head,  laxatives,  and  possibly  diaphoretics  or  diuretics  to  aid  in  the 
excretion  of  ptomaines,  are  all  that  are  requisite.  Accidental  or  operative 
traumatisms  inflicted  upon  those  jireviousl}'  subjected  to  prolonged  brain- 
work,  especially  if  of  a  susce])til)le  nervous  temperament,  occasionally 
give  rise  to  a  delirium  sometimes  called  nervous  trauinatic  delirium. 
This  occurs  without  fever  and  in  those  not  addicted  to  the  use  of 
alcohol.  While  usually  low  and  nuittering,  the  delirium  may  be 
violent,  even   maniacal. 

Prognosis. — This  is  usually  favorable,  especially  if  sufficient  sleep 
can  be  secured. 

Treatment. — Carefully-selected,  nourishing  food,  with  stimulants  if 
requisite,  will  improve  the  nutrition  of  the  nervous  system,  which  has 
suffered  from  the  previous  over-strain.  While  this  is  being  effected  the 
cerebral  centres  must  be  kept  at  rest,  to  prevent  exhaustion,  by  the 
judicious  use  of  opium,  bromides,  chloral,  or  a  combination  of  the  last 
two.     Quiet  of  mind  and  body  should  be  maintained. 

Delirium  Tremens,  or  the  delirium  occurring  in  alcoholics,  is  charac- 
terized in  its  uncomplicated  forms  by  the  absence  of  fever,  but  it  nuist 
not  be  forgotten  that  it  may  occur  after  a  serious  injury,  ^vhich  in  itself 
produces  fever.     The  delirium  is  usually  of  the  low  muttering,  busy, 


TRAUMATIC  DELIRIUM.  375 

vi<>'ilant  form,  with  delusions,  the  patient  seeing  snakes,  insects  of  all 
kinds,  animals,  or  devils,  constantly  conversing  with  himself,  and,  while 
capable  of  answering  rationally  on  other  subjects  than  his  delusions, 
when  left  to  himself  promptly  becoming  again  incoherent.  At  times 
maniacal  outbreaks  occur,  with  suicidal  and  nunxlerous  impulses,  usually 
resulting  from  injury  received  during  alcoholic  excesses:  this  is  true 
mania  d  potu.  Such  apparently  suicidal  acts  as  jumping  from  windows 
are  often  only  eiforts  to  get  away  from  pursuing  de\-ils  or  imaginary  per- 
sons threatening  bodily  injury.  Unless  restrained,  the  patient  will  not 
remain  in  bed,  making  efforts  to  get  up  despite  a  broken  limb.  The  skin 
is  moist,  tlie  hands  siiaking ;  the  tongue  when  protruded  is  trenudous, 
coated  witli  creamy  fur  at  first,  later,  in  bad  cases,  dry,  brown,  and  cov- 
ered with  sordes  ;  the  pulse  is  full,  soft,  and  (juick  ;  and  the  temperature 
is  about  normal.  The  face  and  whole  manner  indicate  suspicion  and 
fear.  Constipation  is  the  rule ;  comi)lete  anorexia  is  present,  although 
fluids  may  be  greedily  swallowed,  and  sleep  is  impossible. 

Prognosis. — If  the  patient  is  young  and  has  sound  kidneys,  recovery 
is  the  rule,  Init  when  the  reverse  olitains  death  by  exhaustion  is  not  un- 
conuuon. 

Treatment. — In  drunkards  attention  to  the  bowels,  anodynes  to  pro- 
duce sleep,  proper  food,  and  lessening  (but  not  stopping)  stimulants  will 
often  ward  off  an  attack,  which  the  experienced  surgeon  anticipates  in 
those  tremulous,  sleepless  individuals  so  often  brought  into  our  large 
hos]>itals.  Traumatisms  inflicted  upon  individuals  who  are  only  mod- 
crate  drinkers  often  suffice  to  bring  on  delii-ium  tremens,  wliich  other- 
wise would  never  have  occurred.  Sudden  withdrawal  of  the  accus- 
tomed stimulant  sometimes  ])recipitates  an  attack. 

During  an  attack  two  indications  are  imperative — viz.  to  induce  sleep, 
thus  jircvcnting  fatal  exiiaustion  of  the  nerve-eeutres,  and  to  maintain 
their  nutrition  l>v  proper  food.  A  laxative  or  an  enema  should  be  given, 
and,  as  liquids  are  usually  acce})table,  tlie  patient  can  be  induced  to  take 
beef-tea  or  meat-broths,  which,  in  the  case  especially  of  old  drunkards, 
will  be  rendered  more  palatable  by  considerable  quantities  of  cayenne 
pe])per,  this  condiment  acting  as  a  stimulant  of  both  digestion  and  the 
cirt'ulatiou.  Occasionally  forced  feeding  Mith  the  stomach-tube  may  be 
requisite.  With  the  older  patients,  where  the  kidneys  are  apt  to  be  dam- 
aged, opium  is  not  advisal)Ie,  but  in  young,  sound  patients  the  hypodermic 
use  of  morphia  may  prove  useful.  Chloral,  in  from  15-  to  20-gr.  dt)ses, 
combined  with  potassium  bromide,  every  two  hours  until  sleej)  is  induced, 
and  carefully  watched,  is  usually  both  safer  and  more  prompt  in  action. 
AVhile  it  may  be  safe  to  at  once  withdraw  all  stiuudauts  from  the  young 
anil  robust,  such  practice  is  not  wise  in  the  old  or  in  feeble  patients. 
That  stimulant  which  tlie  individual  is  accustomed  to  should  be  given, 
but  in  smaller  quantities  than  usual,  and  it  should  be  gradually  with- 
drawn. After  securing  prolonged  sleep,  tonics,  good  food,  and  gradual 
stoppage  of  stimulants  will  usually  effect  a  cure.  The  judicious  use  of 
strychnia  hypodermically  will  aid  this,  while  supporting  the  heart  aud 
nervous  system.  While  it  may  be  pt)ssible  to  secure  to  the  bed  a  jiatient 
who  has  a  fractured  lind),  it  is  exceedingly  difficult  to  avoid  further 
injury  to  this,  a  simple  fracture  often  l)eing  converted  into  a  compoimd 
one.     Where,  owing  to  restlessness,  well-padded  splints  cannot  be  em- 


376    SYMPTOMS  ASD  TREATMENT  OF  TRAUMATIC  HYSTERIA. 

ployed — for  tlie  patient  will  jji-obably  break  a  gypsum  dressing  by  jiound- 
ing  tiie  limb  about — the  limb  uuist  be  enveloped  in  an  antiseptic  dress- 
ing and  then  tirmly  bandaged  in  a  feather  pillow.  If  now  the  injury 
be  rendered  compound,  no  special  harm  will  result.  Securing  patients 
to  the  bed  by  approi)riate  ajjparatus  will  often  be  requisite,  as  they  will 
get  \\\)  and  walk  even  upon  a  broken  liml). 

Traumatic  Hysteria. 

This  term  is  applied  to  tiie  nervous  symptoms  often  observed  after 
severe  physical  shock,  especially  when  combined  with  mental  shock.' 
As  such  comliiuations  are  more  fretjuent  after  railway  accidents,  tlic 
term  "concussion  of  the  sjiine  "  has  been  until  recently  often  applied  to 
the  condition,  or  "  railway  spine,"  but  similar  cases  result  from  other 
forms  of  accident.  Physical  injuries  to  the  nervous  system,  or  the  re- 
sults of  such,  as  inflammatory  or  degenerative  changes ;  the  arousing  of 
latent  pathological  conditions,  with  all  distant  injuries  of  peripheral 
nerves  giving  rise  to  reflex  effects ;  or  an  ascending  neuritis  causing 
central  trouble, — must  not  be  confounded  with  traumatic  hysteria. 

Neurasthenia,  arising  as  it  does  from  "  a  general  defect  in  tiie  mitri- 
tion  and  action  of  the  nervous  system,"  must  not  be  confoimded  ^vith 
traumatic  h3'steria.  According  to  Thorburn,  the  following  complexus 
of  symptoms  is,  with  slight  variations,  constant  after  many  injuries, 
especially  railway  ones  ;  it  follows  tliose  of  shock,  showing  exhaustion  of 
the  nervous  system,  lint  usually  soon  disappears  under  "  time  "  treatment, 
and  must  be  carefully  distinguished  from  iiysteria. 

Symptoms  of  Neurasthenia. — Tiiese  are  "general  debility,  confusion 
of  thought,  loss  of  memory,  mental  irrital)ility,  disturbed  sleep,  dreaming, 
headache  (usually  posterior),  interference  with  visual  accommodation, 
photophol)ia,  palpitation,  frequency  of  pulse,  dyspeptic  troubles  (furred 
tongue,  foul  breath,  constipation,  and  nausea  or  epigastric  pain),  sweat- 
ing, a  concentrated  condition  of  tlie  urine,  etc.""  While  neurasthenia 
is  often  associated  with  hysteria,  and  is  nmch  more  frequent  than  the 
latter,  it  is  probably  a  distinct  condition,  hysteria  being  due  to  "  sug- 
gestion "  or  "  auto-suggestion,"  and  neurasthenia  to  mere  exhaustion. 

Age  predisposes  to  traumatic  hysteria  and  neurasthenia,  these  affec- 
tions belonging  chiefly  to  middle  life.  Hysteria  is  more  likel}'  to  occur 
in  females  if  injured,  but  as  nu)re  males  are  exposed  to  the  causes  of 
traumatic  hysteria,  more  men  actually  suffer  from  it.  A  neurotic  tempera- 
ment and  chronic  alcoholism  both  favor  traumatic  hysteria,  as  they  do 
the  ordinary  form,  but  do  not  have  so  much  influence  as  in  the  latter 
variety,  especially  the    neurotic    tenqierament.     The   exciting  cause  is 

'Oppenheim  calls  these  troubles  traumatic  neuropsychoses.  Thorburn  classifies 
functional  neuroses  following  traumatisms  as  follows :  1.  Acute  effects :  («)  general  nervous 
depression — "shock"  or  "collapse;"  (b)  a  more  localized  and  defined  disturbance  of 
cerebral  (cortical)  origin — "acute  hysteria"  or  "  hysterics."  2.  Chronic  after-effects:  (o) 
general  nervous  depression — "neurasthenia;"  (h)  a  more  localized  and  defined  disturb- 
ance of  cerebral  (cortical)  origin — "  chronic  hysteria."  Thorburn's  definition  of  traumatic 
hysteria  is:  "A  functional  affection  of  the  nervous  system  resulting  from  an  injuiy,  due 
probably  to  a  change  localized  in  some  portion  of  the  cerebral  cortex,  and  manifested  by 
correspondinglv  well-defined  and  localized  symptoms." — A  Contribution  to  the  Surgery  of 
the  Spinal  Cord,  Wm.  Thorburn,  B.S.,  B.Sc,  M.D.  (Lend.),  p.  186  et  seq. 

=  Thorburn:  Op.  cit.,  p.  185. 


TRAUMATIC  HYSTERIA.  377 

some  accident,  but  mental  impressions  Iiave  a  large  share  in  tlie  cansa- 
tion  of"  traumatic  hysteria ;  thus  Thorburn  insists  that  a  previous  period 
of  terror,  horrible  surroundings,  and  the  instantaneous  occurrence  of  the 
accident  have  more  effect  tluui  the  physical  injury.  Direct  injury  to  a 
nerve-trunk  is  a  "potent  cause"  of  hysteria.  While  the  severity  of  the 
traumatism  itself  has  no  special  tletermining  influence,  the  locality  has, 
"complete  hemiantesthesia  or  double  monoplegia"  on  the  same  side  as 
that  of  the  lesion  often  occurring  after  head-injuries.  Surgical  operations 
are  traumatisms,  and  oft«n  give  rise  to  various  functional  neuroses. 

Symptoms. — While  the  ordinary  screaming,  laughter,  crying,  or 
possibly  convulsions  so  often  observed  after  accidents  are  evanescent 
and  of  no  moment,  leaving  at  most  some  temjxn'ary  ner\'ous  exhaustion, 
there  are  certain  peculiarities  observable  at  times,  especially  after  railroad 
accidents.  Thus  patients  will  maintain  that  they  have  been  unconscious 
for  a  longer  or  shorter  period,  yet  investigation  shows  by  the  absence  of 
vomiting,  relaxation  of  the  sphincters,  etc.  that  this  condition  could  not 
have  been  due  to  cerebral  concussion.  Such  patients  walk,  travel  long  dis- 
tances, do  many  voluntary  acts  almost  automatically,  sometimes  regaining 
their  consciousness,  astliey  describe  it,  after  a  considerable  interval  of  time 
and  distance  of  space.  They  present  a  peculiar  dazed  appearance — in  fact, 
resemble  in  many  Avays  those  in  the  somnambulistic  state.  Exaggerated 
or  purely  imaginary  statements  are  made  pertaining  to  the  accident. 
These  illusions  are  ])robably  the  results  of  "auto-suggestion"  during  a 
state  closely  approximating  that  of  the  "minor  degrees  of  hvpnotism."' 
These  preceding  conditions  have  been  called  acute  hysteria,  while  those 
following  belong  to  ciironic  hysteria. 

It  will  be  impossible  to  more  than  mention  the  chief  manifestations 
of  chronic  hysteria.  According  to  Thorburn,  thev  may  be — (1)  psychi- 
cal, including  e[)ileptiform  attacks  and  hysterical  insanity  ;  (2)  motor, 
including  jiaralysis  and  contractures  of  the  limbs  and  special  effects 
upon  the  larynx  and  the  bladder ;  (3)  sensory  symptoms — anesthesia, 
hypersesthesia,  and  paraisthesise  of  the  general  or  sensory  nerves  ;  and 
(4)  vasomotor,  secretory,  and  trophic  troubles."  ^  In  most  eases  symp- 
toms suggestive  of  combined  neurasthenia  are  present. 

Prognosis. — Under  f ivorable  circumstances,  with  proper  treatment, 
and  when  pecuniary  comj^ensation  is  not  sought  or  is  promptlv  granted, 
recovery  seems  frequently  to  take  place.  Chronic  alcoholism,  a  distinct 
neurotic  tendency,  and  the  male  sex  are  unfavorable.  Marked  changes  in 
severity  of  the  symptoms,  transference  from  one  side  to  the  other,  and 
temporary  disappearance  afford  grounds  for  a  favorable  prognosis. 

Treatment. — Isolate  from  friends  and  relatives,  encourage  use  of 
any  paretic  part,  discountenance  the  idea  that  true  paralysis  exists, 
employ  massage  and  faradism,  secure  prompt  settlement  of  legal  ques- 
tions, give  tonics,  possibly  employ  overfeeding,  and  eschew  bromides 
unless  necessitated  by  "  nuich  cerebral  excitement,"  when  "  bromide  of 
ammonium  appears  preferable  to  the  potash  salt."'  Hypnotism  and 
"transference"  have  been'  claimed  to  be  efficacious  in  some  cases. 

'  Thorburn,  op.  cit,  p.  194.  ^  Op.  cit.,  p.  194.  »  Op.  cit,  pp.  224,  225. 


378  SYMPTOMS  AND  TREATMENT  OF  HEMOBBHAGE. 

Hemorrhage. 

Tliis  may  be  arterial,  venous,  or  eapillary,  or  may  arise  from  all  these 
sources.  Unless  arteries  of  a  certain  size  are  divided,  bleedinj^  from  them 
and  from  the  veins  sjiontancously  ceases  and  (■a])il]arv  oozinj^  alone  persists. 
PI(iiiiirrliafi;e  is  called  external  when  occurrinu-  upon  a  free  cutaneous  or 
nuicous  surface — internal  \vlien  the  lilood  is  pnui'cd  into  sucli  cavities  as 
those  of  the  abdomen,  [)ericardiuni,  pleura,  or  mediastiiunn.  This  term  is 
sometimes  also  applied  to  hemorrliages  into  hollow  viscera,  as  the  stomach, 
intestines,  or  bladder.  When  blood  is  poured  out  in  small  amount  into 
the  cellular  tissue  ecehyraoses  or  bruises  result,  while  if  the  anioiuit  be 
large  the  term  "  extravasation  "  is  employed.  Traumatic  hemorrhages 
are  called  "  primary  "  when  immediately  following  tiie  injury;  "inter- 
mediary "  when  they  occur  between  the  stage  of  shock  and  that  marked 
by  suppuration,  tJie  bleeding  I'esulting  either  from  the  increased  vascular 
tension  of  reaction  or  from  coagula  occluiling  vessels  becoming  loosened  by 
the  premature  removal  of  external  ])i-essure ;  "  secondary"  when  they  occur 
after  supjturation  has  been  established,  lieing  due  to  separation  of  sloughs 
in\  olving  the  vessels,  or  to  septic  or  infective  inflannuation  of  the  vessels, 
leading  to  their  ulceration  or  rupture  or  to  the  solution  of  the  occluding 
thrombi ;  "  parenchymatous  "  when  there  is  a  general  capillary  oozing, 
due  cither  to  inflammatory  dilatation  and  canalization  of  the  smaller 
vessels  or  to  throniljosis  of  the  principal  vein  or  veins. 

Treatment  of  Heniorrhag-e. — Great  losses  of  blood  are  dangerous 
because  of  the  risk  of  fatal  syncope.  This  must  be  combated  by  the 
retention  of  a  functioning  amount  of  blood  in  the  l)rain,  especially  iu 
the  respiratory  centres.  The  head  and  shovdders  should  be  promptly 
lowered,  and  this  position  maintained  by  elevating  the  foot  of  the  bed 
some  inches,  neither  ])illow  nor  bolster  being  left  beneath  the  head.  The 
limbs  should  be  raised  nearly  to  a  right  angle  with  the  body,  and  thus 
held.  Sometimes,  instead  of  this,  Ksmarch  or  ordinary  nuislin  bandages 
can  be  applied  to  one  or  all  of  the  lindjs,  or  digital  or  instrumental  com- 
pression of  the  arteries  of  the  limbs  may  be  substituted.  Many  lives 
would  be  saved  if  the  more  essential,  if  not  all,  of  these  measures  were 
instituted  \\here  the  accident  has  occurred,  instead  of  waiting  for  removal 
to  a  hospital,  house,  or  even  to  a  couch. 

Next,  stimulants  by  the  mouth  or  rectum  must  be  employed.  Tur- 
pentine rectal  euemata  act  well.  Subcutancously,  whiskey,  ether,  atropia, 
and  strychnia  will  prove  beneficial.  Artificial  heat  by  hot  bottles,  and 
a  sinapism  over  the  heart,  are  useful.  Transfusion  of  a  saline  solution 
into  the  cellular  tissue  of  the  pectoral  or  abdominal  region,  by  means  of 
a  hypodermic  needle  attached  to  a  few  feet  of  small  rufjber  tubing  and  a 
funnel,  acts  nearly  as  well  as  intravenous  saline  transfusion,  and  is  nuich 
moi-e  readily  done  :  indeed,  considerable  quantities  of  sterilized  normal 
salt  solution  may  be  injected  in  a  .short  time  by  the  rapid  use  of  an  ordi- 
nary hypodermic  syringe.  As  occasion  permits,  concentrated  hot  meat- 
essences,  milk,  hot  coffee,  etc.  must  be  given — /.  e.  liquids  which  when 
absorbed  will  supply  the  heart  with  a  bullv  of  fluid  sufficient  to  carry  on 
its  functions.  As  the  patient  rallies  the  bandages  nuist,  one  by  one,  be 
cautiously  removed,  the  limbs  then  lowered,  but  the  dejjcndent  position 
of  the  head  must  be  maintained  until  all  risk  of  .syncope  has  passed  away. 


HEMORRHAGE.  379 

Later,  iron,  tonics,  and  nutritions  food  are  indicated  to  snpply  tlie  loss 
of  red  cells.  Ergot,  snlplnn-ic  acid,  acetate  of  lead  with  opium,  have  all 
been  occasional!}'  useful  in  recurring  hemorrhages  where  the  bleeding 
points  cannot  be  reached — /.  c.  in  enterorrhagia,  hseniatemesis,  etc. 

H^EMosTASis. — Tiie  local  means  for  temporary  hajmostasis  are  local 
pressure  by  lingers,  com])resses,  tourniquets,  bandages,  etc.  over  the 
wound  or  on  the  l)leeding  vessel  in  the  wound  ;  compression  of  the 
main  vessel  above  or  below  the  wound  by  similar  measures  ;  and  flexion, 
especially  of  the  elbow  or  knee,  for  wounds  of  the  arteries  of  the  hand 
or  foot.  A  compress  should  be  placed  in  front  of  the  elbow  or  behind 
the  knee,  and  the  limb  bent  until  bleeding  ceases,  the  member  being 
thus  maintained  by  a  handkerchief  or  bandage.  Only  such  styptics  are 
permissibk'  as  imitate  or  hasten  Nature's  efforts,  which  are,  in  the  case 
of  arteries,  lessening  of  calibre  and  retraction  within  their  sheaths,  with 
the  formation  of  an  external  and  an  internal  clot,  and  in  veins  their  col- 
lapse and  consequent  thrombosis. 

Exposure  of  wounds  to  the  air  after  removing  all  clots,  a  current  of 
cold  water  flowing  over  their  surfaces,  or  ice  itself  in  the  wounds  or 
api>lied  over  tiie  dressings  by  means  of  an  ice-bag  or  an  ice-bladder,  are 
the  best  means  of  employing  cold. 

Hot  water  (125°-130°  F.,  roughly  estimated  as  the  greatest  heat  bear- 
al)lc  for  a  few  moments  by  the  back  of  the  hand),  poured  over  or  better 
applied  by  pressing  a  towel  wrung  out  of  the  water  on  the  wound,  acts  bet- 
ter tlian  cold  and  docs  not  depress  tlie  vital  powers.  Alcohol  or  tincture  of 
iodine  pure  or  variously  diluted  has  been  successfully  employed  by  some. 
Perchloride  and  subsulphate  of  iron  are  poj)ular  but  unreliable  styptics ; 
moreover,  they  render  asepsis  and  immediate  union  impossible.  While 
Monsel's  solution  is  useful  for  free  bleeding  from  leech-bites,  it  is  better 
even  for  such  accidents  to  transfix  tiie  lips  of  the  minute  wounds  with 
fine  sewing-uecdles,  around  each  of  wiiich  a  figure-of-8  ligature  should 
be  cast.  Tannic  and  gallic  acids  are  less  olijectionable  than  the  iron 
salts,  while  alum  apjjlied  by  means  of  cotton  saturated  in  a  hot  solution 
has  been  much  vaunted  :  probably  pressure  has  much  to  do  with  its  effi- 
cacy, and  an  iodoform-gauze  tampon  would  be  vastly  better.  These 
chemical  styptics  arc  only  mentioned  to  condemn  them,  excejjt  where 
nothing  else  is  available,  as  will  sometimes  occur.' 

The  actual  caatcrji,  applied  at  a  dull-red  heat,  is  most  efficient  when 
primary  union  is  not  aimed  at  or  in  the  peritoneal  cavity,  in  the  latter 
case  no  eschar  being  separated.  The  cautery  is  often  the  only  resort  in 
such  operations  as  removal  of  the  upper  maxilla,  where  the  vessels  can- 
not be  isolated.  The  thermo-cautery  is  the  best  form,  but  any  metallic 
substance,  as  wire,  knitting-needles,  etc.,  can  be  heated  in  the  fire  or  gas. 

Measures  for  the  Permanent  Arrest  of  Hemorrhag-e. — While  the 
cautery  for  certain  cases  and  the  antiseptic  tamponade  may  be  employed 
for  this  purpose,  certain  otiier  measures  are  more  commonly  employed. 

Torsion. — Only  divided  vessels  can  be  twisted.  Drawing  out  the 
whole  cut  end  of  the  vessel  with  one  pair  of  catch-forceps,  grasp  the 
vessel  transversely  close  to  the  tissues  with  a  second  ]iair.  The  end  of 
the  vessel  can  then  be  twisted  off,  or  three  or  four  siiarp  turns  can  be 
given  until  the  inner  and  middle  coats  give  way,  resistance  to  further 

'  In  bleeders,  but  here  the  thermo-cautery  would  be  better. 


380  SYMPTOMS  AND   TREATMENT  OF  HEMORRHAGE. 

torsion  tlien  suddenly  diminishing.  Sniallci"  vessels  which  cannot  be 
isolated  can  be  seized  with  some  of  the  surrounding  tissues,  all  of  which 
should  be  twisted  off. 

Forcipre.ssure  is  effected  by  seizing  the  vessel  or  tissues  with  catt^h- 
forccps,  which  can  be  removed  in  from  a  few  minutes  to  forty-eight 
hours. 

Ligature. — Properly-prepared  silk,  kangaroo  tendon,  and  catgut  form 
the  best  ligatures.  If  tying  a  divided  vessel,  draw  its  end  out  by  for- 
ceps or  a  tenaculum  just  far  enough  to  place  the  thread  securely.  If  in 
dense  tissues,  the  tenaculum  sliould  be  used,  and  slightly  Avithdrawn  as 
the  first  half  of  the  knot  is  tightened.  A  curved  needle  armed  Avith  tlie 
thread  can  sometimes  be  more  conveniently  employed,  passing  it  around 
the  vessels  so  as  to  include  a  little  of  the  surrounding  tissues,  thus  jire- 
venting  the  ligature  from  slipping.  When  tightening  the  knot  the  sur- 
geon's thumbs  or  forefingers  must  jiress  somewhat  down  against  the  for- 
ceps or  tenaculum,  so  as  not  to  j)ull  the  instrument  off  the  vessel  or  out 
of  its  sheath,  this  latter  accident  favoring  secondary  hemorrhage.  When 
the  ligatures  are  to  be  cut  short,  whetlier  silk  or  catgut,  tlic  first  half  of 
the  knot  must  be  tied  only  so  tight  as  th(n-oughly  to  occlude  the  vessel 
and  maintain  its  position,  damaging  the  coats  as  little  as  possible  :  when 
a  ligature  is  to  come  away,  the  aim  is  to  divide  the  inner  and  middle 
coats,  so  that  only  the  external  coat  remains  for  the  thread  to  ulcerate 
through :  both  modern  surgical  practice  and  theory  condemn  this.  A 
"  reef "  or  "  square "  knot  must  be  employed  to  the  exclusion  of  the 
"  granny." 

An  artery  wounded  in  its  continuity  must  be  reached  through  the 
wound  with  the  least  damage  to  parts,  the  proximal  and  distal  ends 
tied,  and  also  any  branch  opening  into  the  part  included  between  the 
ligatures.' 

Mmmres  for  Recurrent  or  Secondary  Hemorrhaf/e. — Ligature  of  the 
bleeding  points,  when  feasible,  followed  by  antiseptic  tamponade  when 
a  cavity  is  concerned,  is  the  best.  As  the  bleeding  from  an  artery  tied 
in  continuity  usually  comes  from  the  distal  extremity,  especially  when 
overlying  a  bone,  a  graduated  comj)ress  and  bandage  may  suffice :  this 
may  be  tried  before  religation  or  amputation.  If  methodic  compression 
is  to  be  employed,  control  the  artery  by  pressure  above,  clear  out  the 
clots,  apply  the  compress  directly  on  the  bleeding  point,  and  secure  it  by 
bandages,  which  must  support  the  circulation  of  the  whole  limb,  below 
and  above.  Not  much  pi-essure  must  ho  used,  and  this  should  be  relaxed 
after  twenty-four  to  thirty-six  hours,  to  prevent  the  formation  of  a  slough 
with  renewed  Ideeding ;  l)ut  the  compress  must  be  allowed  to  come  away 
of  itself.  Where  no  room  remains  for  the  application  of  a  ligature,  the 
wound  may  be  filled  with  shot  or  a  shot-bag  employed  as  a  compress. 
When  all  means  fail,  if  an  extremity  is  involved,  amputation  should  be 
done. 

^  Aciipresmre  may  be  used  to  occlude  a  vessel,  thus:  Pass  a  threaded  needle  through 
the  tissues  beneath  a  vessel,  cast  over  its  jioint  a  loop  of  metallic  wire,  and  compress  the 
vessel  by  securing  the  wire  by  a  turn  or  two  around  the  eye-end  of  the  needle;  traction 
of  the  thread  removes  the  needle,  freeing  the  wire  loop.  Again,  a  long,  stout  steel  pin 
can  be  passed  through  the  skin  and  tissues  at  one  side  of  the  vessel  and  over  it,  and  be 
made  to  emerge  through  the  skin  on  the  opposite  side.  According  to  the  size  of  the 
vessel  the  needle  or  pin  can  be  removed  in  from  thirty  to  sixty  hours. 


HAEMOPHILIA.  381 

HEMOPHILIA. 

This  disease  consists  in  a  tendency  to  excessive  and  continnons  hemor- 
rhages, occurring  spontaneously  or  after  traumatism.  Swelling  of  the 
joints  is  frequently  associated  with  the  external  hemorrhages.  It  is 
congenital,  attacks  males,  and  is  usually  inherited  through  the  mother, 
who  herself  escapes.  The  first  manifestations  nearly  invariably  occur 
before  the  second  year  of  life,  the  ])rimary  bleeding  rarely  appearing 
after  puberty.  In  fact,  after  this  period  the  tendency  to  bleed  dimin- 
ishes. The  oozing,  continuing  for  hours,  days,  or  even  weeks,  is  always 
capillary.  Epistaxis  is  the  most  common  form  of  spontaneous  hemor- 
rhage :  slight  scratches  of  the  skin,  bites  of  the  tongue,  leeching,  blisters, 
extraction  of  teeth,  and  circumcision  are  some  of  the  tranmatic  causes ; 
the  last  three  seem  especially  dangerous.  In  the  sligliter  form  petechia, 
€cchvmoses,  and  hiematomata  may  occur,  either  spontaneonsly  or  from 
trivial  injury.  Jcnner  reports  a  hematoma  extending  from  the  knee  to 
the  trochanter  produced  by  the  fall  of  a  rubber  ball  on  the  tliigh.^  The 
petechife,  which  occur  chiefly  beneath  the  skin  of  the  extremities, 
although  sometimes  seen  on  mucous  and  serous  membranes,  may  be 
accompanied  by  swelling  and  ]>ain  in  the  joints.  Either  with  or  with- 
out these  purpuric  spots  arthritic  complications  are  very  connnon.  These 
vary  from  simple  pain  to  suddenly-develoj^ed  redness  and  intense  inflam- 
mation accompanied  by  fever,  thus  closely  simulating  acute  rheumatism. 
The  knee-,  elbow-,  ankle-,  and  shoulder-joints  are  those  most  usually 
aifected.  Repetition  of  the  attacks  commonly  results  in  marked  deform- 
ity and  disability.  With  the  exception  of  ordinary  anfemia  just  after 
the  bleeding  the  Iilood  is  normal,  wounds  healing  as  in  other  anemic 
patients.  Histohjgical  examination  of  the  vessel-wall  has  only  once 
afforded  confirmation  of  the  statement  of  Blagden,  made  in  1817,"  that 
the  walls  are  unusually  thin,  Ividd  ^  finding  degeneration  of  the  muscular 
tissue  of  the  middle  coat  of  the  arteries  and  proliferation  of  the  endo- 
thelium of  the  arterioles,  veins,  and  capillaries.  Hemorrhage  into  or 
around  the  capsules  of  the  joints  accounts  for  much  of  tlie  articular 
swelling.  Inflammation  of  the  synovial  fringes  and  ulceration  and  de- 
struction of  the  articular  cartilages  have  also  been  reported. 

Pathology. — Although  there  must  be  some  peculiar  frangibility  of 
the  vessels  and  failure  in  prompt  coagulation  of  the  blood,  there  are  no 
histological  or  chemical  facts  explaining  what  these  abnormalities  arc. 

Diagnosis. — In  a  lileeder  family  this  is  easy.  If  occurring  in  a 
member  of  a  family  hitlierto  free,  and  not  resulting  fi'om  slight  pro- 
longed sepsis,  reliance  must  be  placed  on  these  points  :  The  spontaneous 
or  tramnatic  hemorrhages  are  multiple,  joint  complications  are  frequent, 
the  tendency  to  bleed  persists  for  years  :  this  would  constitute  a  congen- 
ital l)lceder,  not  an  hereditary  hicmophiliac,  and  if  a  male,  he  would  be 
likely  to  found  a  "bleeder  family"  if  he  should  have  offspring.  The 
differential  diagnosis  from  simple  hemorrhagic  or  infective  purpura, 
peliosis  rheumatica,  etc.,  mu.st  be  sought  elsewhere. 

Prognosis. — Few  die  from  the  first  bleeding.  The  older  the  patient 
the  better  the  chances,  especially  in  girls,  who  do  not  seem  specially 

'  Legg :   On  HminophUia,  p.  68.         ^  Medko-ckirurg.  Trans.,  vol.  xli.        '  Loc.  cil. 


382  DTAGNOSIS  AND   TREATMENT  OF  HEMOPHILIA. 

prone  to  post-partum  liemorrhages,  although   often  menstruating  early 
and  profusely. 

Treatment. — Prophylaxis  is  imperative ;  all  operative  injuries,  ex- 
traction of  teeth,  and  anything  but  life-saving  (jperations  must  be  inter- 
dicted. In  the  presence  of  hemorrhage  cleansing  of  the  \\(>inid,  followed 
by  pressure,  should  be  employed.  Antipyrine  may  do  good,  while  repeated 
injections  of  cocaine  into  the  gum  has  checked  the  oozing  after  pulling  a 
tooth.  Ergot  by  the  stomach,  purges  of  sodium  sulphate — except  in 
enterorrhagia — large  doses  of  tincture  of  chloride  of  iron,  have  all 
seemed  to  do  good.  Tonics,  iron,  cod-liver  oil,  etc.  are  in<licated  after 
the  attacks,  with  residence  in  a  Avarm  climate.  The  joint-trouliles  must 
be  viewed  as  grave.  If  absolute  quiet  with  moderate  compression  be 
employed,  a  first  attack  often  leaves  an  articidation  normal,  but  when 
untreated  or  repeated  bleedings  occur  an  arthritis  results  resembling 
some  forms  of  tuberculosis.'  While  a  very  dangerous  jirocedure,  Konig 
has  thrice  punctured  the  joint,  using  antiseptic  irrigations,  and  has  had 
two  cures  and  one  improved  case. 

Bertrand  ^  and  Pilcher '  think  that  the  dangers  of  capital  operations 
are  overrated,  because  the  larger  vessels  bleed  no  more  than  in  ordinary 
patients.  While  operations  should  be  avoided  when  possible,  if  they  are 
requisite  careful  ligation  of  the  smallest  vessels,  with  firm  compressing 
bandages  to  control  parenchymatous  bleeding,  will  often  suffice.  If  neces- 
sary, the  actual  cautery  and  tamponade  with  gauze  impregnated  with 
iodoform  or  chloride  of  iron  will  render  success  more  frequent.  Asepsis 
is  imperative,  "  since  secondary  subcutaneous  or  intermuscular  hemor- 
rhages make  the  danger  of  suppuration  "  greater. 

'  Med.  and  Surg.  Reporter,  June  25,  1892,  F.  Konig. 

'  Hiedel :  Inmig.  Dissert.,  1892,  referring  also  to  successes  by  Cramer,  Schede,  Czerny, 
and  Miiller. 

■'  See  Annals  of  Surgery,  p.  499  et  seq.,  vol.  xvii.,  1893  (Pilcher),  for  special  means 
adopted. 


SEPTICiEMIA,  PYEMIA,  AND  POISONED 

WOUNDS. 

By  WILLIAM  H.  CARMALT,  M.  D. 


Septicemia. 


By  septiciemia,  or  septic  or  putrid  fever,  we  understand  a  general 
disease  which  occurs  by  reason  of  the  introduction  into  tlie  circulation 
of  the  products  of  decomposition,  and  which  is  characterized  by  certain 
definite  changes  in  the  blood,  a  typical  succession  of  intlammatory  pro- 
cesses, and  a  continued  fever  with  jicculiar  nervous  symptoms  and  cuti- 
cal  secretions.' 

This  definition,  in  allowing  us  to  include  the  absorption  of  the  prod- 
ucts of  decomposition,  without  the  actual  presence  in  the  blood  of  the 
micro-organisms  thereof,  conforms  to  the  clinical  phenomena  as  we  find 
them  in  surgical  practice.  Cases  of  I'xtensive  sulx'utaneous  lacerations, 
followed  by  fever  and  other  clinical  phenomena  of  the  absorption  of 
septic  material,  are  of  frequent  dccurrcncc,  yet  the  most  careful  investi- 
gation does  not  reveal  the  presence  of  infective  micro-organisms.  The.se 
cases  are  regarded  as  instances  of  the  absorjition  of  the  chemical  sub- 
stances, toxines  or  ptomaines,  produced  in  the  decomposition  of  the  blood- 
clot,  ])oisonous  in  their  action,  causing  a  form  of  septic  intoxication  to 
which  Matthews  Duncan  gave  the  name  of  "  saprsemia." 

In  a  few  hours — variably  from  twelve  to  seventy-two — after  the 
reception  of  a  subcutaneous  laceration  of  the  soft  parts,  with  extrav- 
asation of  blood  into  the  connective  tissue,  or  after  a  surgical  operation 
in  which  the  hsemo.stasis  has  not  been  complete,  or — taking  an  illustration 
out  of  strict  surgical  practice,  though  of  like  pathological  significance — 
after  the  act  of  parturition,  a  disturbance  shows  itself,  usually  first  noticed 
on  the  part  of  the  nervous  system.  The  jiatient  has  a  headache,  a  flushed 
face  ;  the  appetite  fails  ;  there  may  be  nausea ;  there  is  a  marked  feeling 
of  depressi(jn,  even  anxiety  ;  there  may  or  may  not  have  been  a  slight 
chill ;  the  temperature  is  from  100°  to  102°  F.  or  more ;  the  tongue 
becomes  dry,  and  air  acute  sense  of  smell  will  perhaps  detect  a  .slight 
odor  to  the  wound  or  discharge.  If  the  projier  treatment  be  not 
immediately  instituted,  these  .symptoms  increase,  though  not  uniformly 
so  in  all  cases :  headache  may  not  be  complained  of,  but  the  senso- 
rium  becomes  greatly  blunted ;  the  patient  is  apathetic,  lies  rather  in 
a  stupor,  and,  though  answering  f|uestions  intelligently,  is  slow  to  be 
aroused;  the  nausea  becomes  more  pronounced;  the  food  is  vomited ; 
the  temperature  keeps  up  all  the  time,  in  the  afternoon  rising  a  degree 

'  Gussenbaur :  "  Sephthiimie,  Pyohiimie,  und  Pyo-sephthiimie,"  p.  2,  Deutsche  Chi- 
rurgie,  Lief.  4. 

383 


384  SEPTICAEMIA,  PYAEMIA,  AND  POISONED    WOUNDS 

or  over,  ranging  between  101°  and  103°  F. ;  the  tongue  becomes  drier, 
perhaps  not  more  coated ;  tlie  patient  at  times  is  delirious,  able  to  answer 
if  aroused,  though  not  always  correctly  ;  the  pulse  becomes  rapid  and 
feeble,  the  respiration  Juirricd  and  superficial ;  if  drink  is  offered,  it  will 
be  taken  with  avidity,  but  the  patient  does  not  ask  for  it;  the  sensoriuni 
is  benumbed ;  the  muscular  strength  fails  greatly,  aud  the  patient  sinks 
down  in  the  bed.  In  bad  cases  these  symptoms  increase  rapidly :  the 
benumbing  of  tlie  sensorium,  as  shown  in  the  stupor  and  delirium,  be- 
comes greater,  the  heart's  action  more  feeble  ;  there  may  be  subsulfus 
tcii(Uimiii;  the  half-closed  eyes  become  glazed  with  mucus,  which  col- 
lects upon  the  cornea  and  around  the  edges  of  the  lids ;  if  care  be  not 
taken,  involuntary  discharges  of  urine  occur  from  overflow  of  the  blad- 
der, the  jxitient  being  unconscious  of  the  distention  ;  the  bowels  are 
constipated,  and  if  a  cathartic  be  administered  the  discharge  will  be 
unnoticed  ;  the  face,  at  first  flushed,  liecomes,  as  the  heart's  action  fails, 
dusky  and  livid,  and  death  comes  on  the  fourth  or  fifth  day. 

With  all  these  grave  constitutional  disturbances,  however,  it  is  to 
be  remarked  that  there  are  but  few  changes  in  the  wound-surface ;  the 
odor  of  decomposition  may  remain,  or,  if  the .  parts  are  not  thoroughly 
washed,  it  may  increase ;  but  the  tissues  around  the  cut  surfiice  do  not 
show  any  changes  to  indicate  that  they  have  become  the  seat  of  deposits 
of  micro-organisms,  nor  does  the  post-mortem  examination  show  the 
ckiudy  swellings  in  the  parenchymatous  organs  associated  with  septi- 
caemia. The  clinical  phenomena  are  those  of  the  nervous  system  being 
overwhelmed  by  the  action  of  a  substance  resembling  a  narcotic  poison. 

In  milder  cases — i.  e.  those  in  which  the  amount  of  poison  absorbed 
has  not  been  great,  or  in  which  a  rational  treatment  has  been  promptly 
and  successfully  instituted — the  symptoms  disappear  as  rapidly ;  the 
headache  and  other  nervous  disturbances  pass  off;  the  appetite  returns; 
the  pulse  regains  its  tone  and  strength,  and  the  temperature  becomes 
nomial. 

The  prognosis  depends  upon  three  factors  : 

First :  the  amount  of  })oison  absorbed — as  for  other  poisons,  upon  the 
dose  administered.  Regarding  the  disease  as  due  to  direct  absoi'ption 
of  the  poisonous  products  of  decomposition,  and  not  to  the  presence  of 
micro-organisms  multiplying  in  a  fertile  culture-medium,  it  is  evident 
that  a  large  dose  will  have  more  effect  than  a  siuall  one.  This  depends, 
therefore,  either  on  the  size  of  the  blood-clot  undergoing  the  decompos- 
ing processes,  or  on  the  extent  of  tissue  destroyed  from  which  the  toxine 
is  evolved  to  be  distributed  to  the  nervous  system,  upon  which,  it  is  evi- 
dent, it  most  powerfully  acts.  In  this  there  is  a  striking  contrast  to 
other  more  positive  septicemic  processes,  where  a  small  wound — -the 
prick  of  a  needle  or  a  scalpel  in  a  dissecting  wound — is  followed  later 
by  extremely  serious  consequences. 

Second:  the  time  M'hich  elapses  before  the  proper  treatment  is  applied  : 
the  longer  the  poison  acts  by  its  depressing  influence  upon  the  nervous 
system,  the  higher  the  pulse  and  temperature  become,  the  more  are  they 
using  up  the  ^jatient's  vital  forces. 

Third:  the  constitutional  habit — viz.  the  strength  of  the  individual 
to  resist  the  action  of  the  poison.  This  factor  does  not  require  explana- 
tion ;  it  is  the  same  for  all  diseases.     The  prognosis,  of  course,  is  more 


SEPTICEMIA.  385 

unfavorable  in  the  exti'emes  of  age  or  if  this  disease  be  complicated  with 
some  other. 

The  treatment  consists,  first,  in  removing  the  source  of  the  disease, 
removing  all  blood-clots,  and,  if  it  be  a  wountl,  washing  off  the  absorbing 
surface.  In  this  condition  the  use  of  germicidal  solutions — the  so-called 
antiseptics — is  no  more  beneficial  than  that  of  sterilized  water.  The  only 
advantage  they  have  is  in  the  destruction  of  any  possible  germs,  or  their 
spores  which  may  not  yet  have  become  active,  but  which,  under  favor- 
able conditions,  are  likely  to  become  so  and  to  lead  to  more  serious  dis- 
ease. Blood-clots  and  all  matters  which  serve  as  a  basis  for  the  devel- 
opment of  the  products  of  ilecomposition  must,  however,  be  thoroughly 
removed  and  their  fiirtlier  ccjllcction  be  prevented. 

It  depends  on  the  violence  of  the  s)-mptoms  as  to  how  far  we  must 
go  in  exposing  a  raw  surface  for  the  purpose  of  getting  rid  of  the  poison  : 
a  single  thoi'ough  washing  out  of  the  uterus  after  parturition  is  often 
sufficient  to  reduce  the  temperature  to  normal  without  a  relapse ;  occa- 
sionally it  is  required  to  repeat  it  a  few  times  at  lengthened  intervals,  or 
in  other  cases  it  must  be  done  every  few  hours.  In  the  case  of  Mounds 
where  we  are  hoping  to  get  union  by  first  intention,  a  single  washing  out, 
with  pressure  firmly  applied  over  the  skin  of  the  stump  (if  it  be  an 
amputation),  will  frequently  suffice.  If  this  does  not  answer  the  pur- 
pose, the  introduction  of  a  drainage-tube  becomes  necessary,  and  more 
frequent  cleansing  with  the  more  positive  germicides,  owing  to  the 
danger  tliat  septicemia  may  take  the  place  of  sapra'mia.  Alercuric 
bichloride  in  the  proportion  of  1  :  2000-10,000,  and  carbolic  acid  in 
from  1  to  3  per  cent.,  are  at  this  period  of  great  value.  The  further 
carrying  out  of  local  treatment  is  included  in  that  of  septicsemia. 

The  treatment  of  the  constitutional  condition  consists  in  strengthen- 
ing the  action  of  the  heart  and  that  of  the  general  system  by  the  admin- 
istration of  stimulants :  whiskey,  St.  Croix  rum,  and  brandy  in  milk- 
punch  or  egg-nog  are  preferable,  as  thereby  nourishment  is  also  given  ; 
quinia  or  tr.  cinchona  is  of  great  value,  but  the  use  of  the  recently- 
invented  antipyretics  is  of  little  benefit. 

In  a  certain  number  of  cases,  where  the  amount  of  poison  evolved 
and  absorbed  is  not  sufficient  to  cause  the  death  of  the  patient,  and  in 
which  treatment  is  not  ])ropcrly  instituted  for  recovery,  in  the  course  of 
some  days  another  condition  of  the  general  system  is  brought  about,  due 
to  further  changes  in  the  blood-clot  and  in  the  neighboring  tissues.  The 
micro-organisms  producing  the  putrefaction  of  the  clot  penetrate  in  time 
into  the  several  blood-vessels  of  the  woiuidcd  part,  there  finding  a  soil 
more  fertile  for  their  further  multiplication  and  development.  A\'e  then 
have  another  set  of  symptoms,  in  many  respects,  it  is  true,  similar  to  those 
of  the  septic  intoxication,  but  with  tiiis  important  difference — that  their 
severity  is  due  not  so  much  to  tne  amount  of  a  poison  absoi'bed  as  to  the 
activity  of  growth  of  the  bacteria.  In  other  instances  than  the  one  men- 
tioned of  a  retained  blood-clot  we  find  the  same  set  of  symjitoms  fc>llow)ng 
trivial  as  well  as  severe  injuries — the  mere  prick  of  an  infected  lancet, 
the  most  indifferent  scratch.  I  have  in  mind  the  prick  of  a  wooden 
toothpick  received  in  the  hand  in  takijig  it  out  of  the  pocket,  necessi- 
tating subsequently  the  amputation  of  the  arm  to  preserve  life :  medical 
literature  reports  similar  cases  in  abundance.     It  is  only  necessary  that 

Vol.  I.— 25 


386 


SEPTICEMIA,  PYJEMIA,  AND  POISONED   WOUNDS. 


the  bacteria  be  given  access  to  tlio  circulation  in  order  that  the  disease 
may  be  set  up ;  an  evident  wound  is  not  necessary.  It  must  not  be 
understood,  liowever,  tliat  all  persons  thus  injured,  who  are  subjected  to 
the  same  infection,  respond  ecjually  and  are  su"scci)tible  in  a  like  degree  to 
the  deleterious  effects.  It  would  seem  that  all  blood  is  not  equally  good 
soil  for  the  growth  of  the  germs,  or  tiiat  the  tissues  of  some  persons 
resist  their  action,  so  that  the  general  infection  does  not  follow  the 
exposure,  and  the  individual  escapes. 

The  infection  in  septicaemia  is  shown  botli  locally  and  constitutionally, 
but  not  uniformly  in  either  way.  It  depends  largely  on  the  character  of 
the  wound,  but  in  some  degree  also  upon  tlu'  virulence  of  the  infection. 
In  cases  of  open  wounds,  such  as  compound  fractures  or  severe  lacera- 
tions of  the  soft  parts,  including  the  skin,  with  I'ontaniiuatiou  of  the  tis- 
sues, a  class  of  wound  most  frequently  followed  by  septicsmia  running  a 
typical  course,  the  skin  at  the  seat  of  injury  becomes  reddened,  swollen, 
and  painful,  and  the  wounded  surface  becomes  covered  with  a  dirty- 
looking,  somewhat  thick  secretion,  which  will  jiartially  wash  off,  but 
leaves  the  tissue  underneath  of  a  dull,  more  or  less  variegated  gray 
color,  -without  distinction  between  different  anatomical  parts,  with  a 
superficial  slough  and  an  ajipreciable  odor  of  decomj)osition.  This  last 
is  an  exceedingly  important  symptom,  to  be  sought  for  early  with  great 
care;  and  it  may  be  here  stated  that  the  great  objection  to  iodoform  as  a 
dressing  for  fresh  wounds  is  that  Ijy  its  strong  odor  it  masks  the  first 
positive  evidences  we  have  of  putrefaction,  anil  in  just  so  far  increases 
the  danger  of  acquiring  the  general  condition  of  scpticiemia.  At  the  time 
that  these  changes  appear  in  the  wound,  or  very  soon  afterward,  the 
general  system  shows  evidences  of  participation,  in  that  the  temperature 
rises — it  may  be  a  degree  or  two,  it  may  l)e  more — the  pulse  and  resj)ira- 
tion  are  accelerated,  the  tongue  becomes  coated,  and  the  })atient  complains 
of  a  general  sense  of  discomfort ;  in  other  words,  an  active  febrile  move- 

FiG.  10. 


ment  with  some,  but  not  severe,  evidences  of  affection  of  the  nervous 
system,  inasmuch  as  stupor  and  aj)athy  are  not  so  prominent,  in  this 
respect  differing  from  the  condition  of  saprtemia  or  septic  intoxication 
just  described.     The    fever  is   continuous,   but   with    morning   remis- 


SEPTICEMIA.  387 

sions  and  afternoon  exacerbations,  gradually  on  successive  days  rising 
higher  and  higher — the  morning  remission  not  reaching  that  of  the 
previous  day — until  the  acme  is  reached  :  this  occurs  about  the  fourth 
■or  fifth  day,  when,  ^^•ith  the  appearance  of  suppuration  in  the  wound, 
the  constitutional  symptoms  abate  and  the  fever  sul)sides  l)y  a  similar 
gradation  of  declining  steps  at  each  day,  though  more  rapidly  than 
it  arose,  so  that,  while  it  Avas  from  three  to  six  days  rising,  it  falls 
in  from  two  to  four  days  to  a  nearly  or  quite  normal  temperature.  The 
temperature-chart  of  a  typical  case  of  septicaemia  going  on  to  recovery 
is  sliDwn  in  tlie  accompanying  diagram  (Fig.  10)  of  a  case  of  com])ound 
comininuteil  fracture  of  both  Ijones  of  the  leg  by  a  railroad  injury, 
occurring  in  an  otherwise  healthy  man  of  about  twenty-five  years  of  age. 

The  character  of  the  wound,  the  method  or  al)sence  of  treatment  em- 
ployed, the  nature  of  the  infective  material  with  which  it  is  contaminated, 
and  the  constitutional  condition  of  the  individual  as  to  power  of  resisting 
the  invasion  of  the  infective  micro-organisms  and  the  develoj)ment  of  the 
toxines,  arc,  however,  factors  that  modify  the  course  of  the  disease,  both 
locally  and  constitutionally,  in  a  great  variety  of  ways.  It  is  of  the 
highest  interest  to  surgeons  to  know  just  how  to  meet  the  manifold 
phases. 

The  septic  process  may  spread  locally  along  certain  definite  anatomical 
lines  ;  it  may  invade  all  the  tissues  of  a  limb  or  a  part,  attacking,  perhaps 
■destroying,  every  tissue  that  it  meets.  The  most  frequent  anatomical 
site,  however,  is  perhaps  the  connective  tissue,  where,  owing  to  the  loose 
arrangement  of  lymph-spaces,  vessel-sheaths,  and  intermuscular  planes, 
the  development  of  the  bacteria  is  given  every  facility,  and  where  they  do 
grow  almost  witliout  limit.  These  are  the  cases  of  cellulitis  so  constantly 
met  with  in  the  hands,  less  fretpiently  in  the  feet,  of  tradespeople  and 
those  who  are  exposed  to  infection  from  their  occupation.  Wo  find  them 
arising  from  the  most  trivial,  many  times  undetected,  injuries,  usually 
spreading  rapidly,  with  great  pain  and  swelling. 

In  other  instances  entrance  is  gained  into  the  sheaths  of  the  tendons, 
and  tendo-vaginitis  of  an  exceedingly  severe  character  is  excited,  often 
going  on  to  suppuration,  extending  into  the  palm  of  the  hand,  and  so  on 
up  to  the  wrist,  with  the  result  of  the  impairment,  if  not  absolute  aboli- 
tion, of  function  by  the  destruction  of  the  sheath  from  sloughing  or  from 
the  necessary  treatment  in  laying  it  fi'eely  open,  the  subsequent  cicatriza- 
tion producing  adhesions  obliterating  the  sheath,  or  so  attaching  it  to 
neighboring  ])arts  as  to  prevent  the  normal  play.  These  cases  are 
intensely  j>ainful,  owing  to  the  confinement  of  the  swelling  inside  the 
fibrous  sheatlis,  and,  while  not  so  deforming  as  when  the  connective  tissue 
alone  is  involved,  the  integrity  of  the  hand  is  in  greater  danger  even  if 
am]>utation  be  avoided. 

The  various  distributions  of  the  lymphatic  system  serve  frequently, 
both  in  common  with  the  connective  tissue  and  alone,  as  media  for 
the  transmission  of  the  micro-organisms  :  it  may  be  as  a  simple  lymph- 
angitis or  lymphadenitis,  and  we  may  regard  septic  osteomyelitis  as 
belonging  here.  These  cases  are  always  serious  by  reason  of  the 
very  great  facility  with  which  they  spread,  either  continuously  along 
the  course  of  the  vessels,  or  more  erratically,  leaping  from  one  set  of 
glands  to  another,  sometimes  quite  at  a  distance,  each  set  serving  as  a 


388  SEPTICEMIA,  PYAEMIA,  AND  POISONED    WOUNDS. 

focu.s  for  the  storing  up  and  further  di.strihution  of  the  bacteria.  Occa- 
sionally they  suppurate,  though  they  usually  do  not,  but  where  they  do 
it  simulates  pyajmia,  and  tlie  diagnosis  is  then  difficult.  The  more  acute 
course,  coming  on  before  supi)uration  has  appeared  in  the  wound ;  the 
character  of  the  fever,  being  continuous  instead  of  intermittent;  the  ab- 
sence of  repeated  chills  and  the  torpor  of  the  nervous  system, — determine 
clinically  the  septic  rather  than  the  purulent  character  of  the  process,  as 
is  confirmed  at  the  autopsy  by  the  absence  of  abscesses  in  the  parenchy- 
matous organs. 

The  most  virulent  form  of  septic  infection,  however,  appears  in  the 
immediate  invasion  of  all  the  tissues  of  a  part — skin,  connective  tissue, 
muscles,  lymphatic  vessels,  and  blood-vessels.  This  invasion  is  of  great 
gravity,  and  comes  on  usually  as  the  residt  of  extensive  injuries  to  both 
soft  parts  and  bones. 

A  man  of  not  very  robust  physique,  but  otherwise  in  good  health, 
had  his  left  foot  causrht  between  an  elevator-car  and  the  floor  above  in 
such  a  way  that  most  of  the  sole  of  the  foot,  including  the  tuberosity  of 
the  OS  ealcis,  was  nearly  crushed  off.  The  ragged  skin  and  enclosed 
pulpefied  mass  of  bruised  tissue  were  stitched  together  by  an  incompetent 
practitioner,  bandaged  firmly  with  cotton  roller  bandages  halfway  u])  to  the 
knee,  and  left  practically  without  further  treatment.  He  was  admitted  to 
the  New  Haven  Hospital  on  the  fiiurth  day  after.  There  was  an  extremely 
offensive  odor  of  putrefaction  ;  the  foot  was  black  and  gangrenous;  the 
whole  injui'ed  portion  and  the  leg  to  just  above  the  knee  swollen,  emphy- 
sematous, and  of  a  peculiar  shiny-brown  or  bronzed  color — not  reddish. 
This  color  had  been  noticed  only  on  the  day  previous  to  admission,  but 
had  advanced  rapidly  after  making  its  first  appearance.  The  pulse  was 
about  105,  of  good  force;  the  intellect  clear;  there  was  considerable^ 
pain  in  the  leg.  The  temperature  was  100^°  F.  A  free  incision  was 
made  about  halfway  to  the  knee  at  the  spot  where  the  emphysema  was 
most  evident ;  no  pus  was  found,  but  the  w^ound  discharged  a  thin  sani- 
ous  fluid  of  a  more  or  less  yellowish  color,  mixed  with  gas,  and  gas  could 
be  pushed  out  of  the  wound  in  the  foot  from  above  ;  the  incision  through 
the  skin  scarcely  bled  ;  there  was  no  undermining  of  the  skin  or  opening 
of  the  muscle-planes,  and  it  was  impossible  to  get  a  drainage-tube  in 
Avithout  breaking  through  fresh  tissue.  An  active  system  of  antiseptic 
irrigation  was  instituted,  but  the  infection  of  the  tissues  continued  to 
advance,  and  the  next  morning  the  discoloration  was  two  inches  higher  y 
the  temperature  a  trifle  higher,  100j*g°,  the  pulse  80,  the  mental  conditiou 
Still  good.  That  the  foot  would  require  amputation  was  without  question, 
and  the  advancing  infection  of  the  leg  made  it  appear  as  if  it  would  be 
necessary  to  take  the  leg  ofl'  high  up,  above  the  knee,  to  save  life,  but 
the  very  rapid  advancement  left  it  uncertain  just  where.  In  the  after- 
noon the  discoloration  had  reached  the  irregular  line  shown  in  the  illus- 
tration (Fig.  11)  taken  from  a  photograjjli.  At  this  time  the  temperature 
was  101^°,  the  pulse  115  and  more  feeble,  but  there  was  no  stupor  or 
other  disturbance  of  the  nervous  system  other  than  could  be  accounted 
for  by  the  natural  anxiety  of  what  the  outcome  was  to  be,  for  it  now 
looked  as  if  the  thigh  must  be  ami)utated  in  the  upper  third,  if  not  at 
the  hijJ-joint.  During  the  next  night  there  was  no  advancement  of  the 
discoloration,  and  the  temperature  had  fallen  to  101°,  in  the  afternoon 


SEPTICAEMIA.  389 

to  101  j^°,  and  from  this  time  tliore  was  a  steady  subsidence  of  the  un- 
toward symjttoms,  Ijoth  locally  anil  constitutionally,  .so  that  on  the  ninth 
day  after  admission  I  was  able  to  amj)utate  at  aliout  the  middle  of  the 
leg.     The  tissues  at  the  site  of  the  operation  still  showed  evidences  of 

Fio.  11. 


Bronzed  discoloration  of  skin  of  leg  and  tliigh  following  traumatic  gangrene  of  foot,  appearing 
third  day  after  injury— photograph  taken  second  day  thereafter.  (From  records  of  New  Haveu 
Hospital.) 

the  diseased  condition  in  that  they  were  infiltrated  with  serum  and  did 
not  heal  by  first  intention,  but  the  course  of  the  operation  was  almost 
aseptic  throughout  in  that  the  rise  in  temperature  on  the  afternoon  of 
the  day  following  the  operation  was  lOOj^g-"  F.,  falling  at  the  next  obser- 
vation to  normal. 

The  fortunate  result  in  this  case  cannot  be  regarded  as  the  rule,  how- 
ever, in  cases  of  general  septic  infection  with  traumatic  gangrene,  as  is 
illustrated  in  another  case,  likewise  under  my  care  at  the  same  hospital, 
where  a  woman  of  fifty-eight  was  subjected  to  the  manipulations  of  a 
notorious  "bone-setter"  for  a  dislocation  of  the  left  shoulder-joint  of 
two  weeks'  duration.  After  jirolonged  and  violent  attempts  at  reduc- 
tion the  arm  was  finally  left  with  the  elbow  bound  firmly  to  the  side 
and  a  pad  in  the  axilla.  I  saw  it  first  three  days  afterward  :  the 
arm  was  then  black  and  gangrenous  to  the  elbow,  with  great  swelling 
and  a  reddish  discoloration  of  the  arm  above.  The  pain  was  severe, 
the  pulse  of  the  opposite  arm  rapid  and  feeble ;  the  temperature  was 
102°  F. ;  the  patient  was  alert  in  mind,  aware  of  her  danger,  and 
anxious  to  have  the  arm  removed ;  the  tongue  was  already  dry,  and 
there  had  been  some  vomiting.  Amputation  was  deferred  to  try — first, 
to  improve  the  heai't's  action  by  stimulants ;  second,  to  try  the  eifect  of 
anti.septic  treatment  in  reilucing  the  fever ;  third,  to  see  if  some  line  of 
demarcation  would  not  show  itself.  The  first  only  of  these  desiderata 
came  about :  the  heart  did  gain  strength,  but  the  putrefaction  inci'cased, 
the  swelling  and  redness  extended  over  the  shoulder,  and  began  to 
invade  the  neck.  On  the  first  day  after  admission  the  temperature  was 
103y\j-°  F.,  falling  the  next  morning  to  100^*^°  F.,  and  rising  in  the  after- 
noon to  l()3/jy°  F.  ;  the  tongue  continued  dry.  Incisions  were  made  in 
the  arm  for  the  purpose  of  washing  it  out  antiseptically.     It  being  evi- 


390  SEPTICEMIA,  PYAEMIA,  AND  POISOXED    WOUNDS. 

dent,  however,  that  the  sepsis  was  increasing,  and  the  patient's  general 
condition  not  improving,  tiie  arm  was  am])ntated  at  about  the  middle  on 
the  second  day.  At  the  operation  it  was  found  that,  instead  of  a  dislo- 
cation, there  was  a  fracture  of  the  sui-gieal  neek  (whether  this  was  the 
original  injury  or  was  produced  by  the  violent  etforts  made  to  reduce 
the  tlisloeation  could  not  bo  told),  and  that  all  the  tissues  at  the  line  of 
amputation  were  intiltratcd  witii  a  foul-smelling  serum,  particularly  in 
the  intermuscular  planes  of  connective  tissue.  The  bone  was  removed 
at  the  seat  of  fracture,  and  the  sinus  thus  left  was  mopped  out  with  ])ure 
carbolic  acid,  and  the  wound  freely  irrigated  with  mercuric  bichloride, 
1  :  1000.  There  was  a  decided  imjn'ovement  in  her  condition  immedi- 
ately and  for  a  few  days  following  the  operation ;  the  temperature  fell 
to  iOO°  F.,  but  her  heart  failed  ;  she  was  soon  after  attacked  with  a 
septic  gastro-enteritis,  causing  profuse  watery  discharges,  \vhich  became 
choleraic  later  and  involuntary  ;  her  stomach  refused  to  retain  anything  j 
she  became  indifferent  to  her  surroundings,  and  finally  comatose,  dying 
in  this  condition  thirteen  days  after  the  injury,  eight  days  after  the 
amputation.  This  gastro-enteritis  is  not  unusual  in  severe  cases,  and  is 
regarded  by  Gussenbaur  as  directly  due  to  the  action  of  the  products  of 
the  septic  micro-organisms  uixin  the  intestinal  tract. 

While  these  two  cases  bear,  in  their  local  action,  a  marked  resemblance 
to  the  ffcmgrene  foudroyante  of  Maisonneuve,  there  is  an  imjJortant  differ- 
ence in  the  symptomatology — viz.  that  the  nervous  symptoms  were  by  no 
means  so  prominent.  In  the  case  of  the  wound  of  the  foot,  although  the 
local  progress  was  most  rapid,  to  l)e  seen  advancing  almost  from  hour  to 
hour,  the  patient's  mind  was  clear  :  he  ap])reciated  the  danger  of  his  situa- 
tion, was  desirous  to  have  whatever  done  that  his  medical  adviser  deemed 
best,  and  was  in  no  way  either  apathetic  or  over-anxious  as  to  his  situa- 
tion. In  the  other  case  it  was  not  until  just  before  the  arm  was  ampu- 
tated, five  days  after  the  injury,  that  the  torpidity  of  the  intellect  as 
given  by  Maisonneuve  became  a  prominent  symptom.  His  cases  are 
described  as  "being  from  the  l)eginning  in  a  condition  of  complete 
apathy ;  the  wound  and  its  parts  affected  by  the  septic  infection  are 
almost  painless;  the  patient  does  not  ask  for  drink,  though  his  dry 
tongue  cleaves  to  his  gums,"  though  in  other  cases  there  is  great  rest- 
lessness, indeed  manifest  delirium,  with  unconsciousness  of  surround- 
ings and  disposition  to  toss  about  in  spite  of  the  injuries ;  the  skin  is 
bathed  in  perspiration  ;  the  urine  and  tVeces  are  passed  involuntarily ; 
the  respiration  is  hurried  and  superficial,  the  jjulse  weak  and  intermit- 
tent ;  in  other  words,  there  is  a  condition  of  extreme  collapse,  in  M'hich 
the  fatal  termination  appears  in  from  twenty-four  to  ninety-six  hours. 
In  the  cases  which  last  long  an  icteric  hue  to  the  skin  becomes  evident, 
showing  the  effect  of  the  jioison  on  the  liver,  which  on  autopsy  is  usu- 
ally found  swollen  and  soft. 

This  description  is  very  like  that  given  of  septic  intoxication 
(sapraemia),  but  we  are  taught  that  in  this  the  local  changes  are  as 
nothing.  It  is  therefore  evident  that  the  most  active  fulminating  putre- 
factive local  ]irocess  may  go  on  for  days  in  an  extremity,  with  no  absorp- 
tion taking  place  of  the  products  of  decomposition  to  affect  the  cerebral 
functions,  and  finally  recover;  and,  further,  that  symptoms  identical 
M-ith  this  acute  disease,  saprsemia,  may  come  on   as  a  secondary  fever 


SEPTICEMIA. 


391 


several  days  aftei"  the  reception  of  the  injury,  an  intermediary,  compar- 
atively afebrile,  stage  being  passed  through. 

The  effect  of  the  septic  infei'ticin,  as  has  been  stated,  is  much  the  most 
marked  in  the  systemic  disturbances  ;  the  tissue-changes,  aside  from  tiie 
direct  injury,  are  not  very  great.  They  consist  in  an  interference  with 
or  a  cessation  of  the  proper  process  of  repair,  rather  than  in  active 
destruction.  There  are  cases,  however,  where  the  local  destruction  is 
excessive,  as  in  tlie  gangrenous  stomatitis  or  cancrum  oris  of  children.  A 
characteristic  instance  of  this  occurred  in  my  service  at  the  New  Haven 
Hospital.'  We  have  here  to  deal  with  the  invasion  of  the  tissues  by  the 
bacteria  to  such  an  extent  as  to  destroy  them  en  masse.  It  is  not  a 
question  of  a  cutting  off  of  the  blood-sujjply  by  an  embolic  process, 
as  in  gangrene  of  a  limb,  nor  of  the  destruction  of  the  vitality  of  the 
tissues  by  a  violent  force,  as  in  railway  injuries,  nor,  again,  of  the  infec- 
tion of  the  system  from  a  trivial  injury,  as  in  a  dissecting  wound,  but 
the  almost  sinudtaneous  destruction  of  all  the  tissues  of  the  part  Ity  the 
apparent  invasion  of  the  wiiolc  by  countless  myriads  of  bacteria  of 
various  kinds,  staphylococci,  streptococci,  and  micrococci  all  being  found. 
These  cases  usually  occur  in  children  already  reduced  in  vitality  by 
some  debilitating  disease,  as  typhoid  fever,  but  in  whom  access  to  the 
tissues  by  the  micro-organisms  is  obtained  by  some  slight  abrasion — in 
this  the  picking  at  a  tooth  witli  her  tinger-nails  produced  a  slight  abra- 
sion which  rapidly  increased  U)  an  area  of  iuHannnatiou,  followed  by 


Fig.  12, 


Gangrenous  stomatitis  following  tvplidid  fovor  about  twilfth  day  after  beginning  of  ulceration. 
(Records  of  Now  Haven  Hospital.) 

necrosis  and  gangrene,  so  that  mIicu  I  first  saw  her,  about  ten  days 
from  the  beginning  of  the  local  trouble,  there  was  an  area  of  gangrene 
involving  the  entire  thickness  of  the  cheek  from  near  the  median  line 

*  Dr,  C.  J.  Foote,  in  the  American  Journal  of  Med.  Scknces,  Aug.,  1893. 


392  SEPTICEMIA,   PY.EMIA,  AND  POISONED   WOUNDS 

to  beyond  what  had  been  the  angle  of  tlie  month,  exposing  both  upper 
and  lower  jaw-bones ;  the  teeth  were  loosened  from  their  sockets ;  shreds 
and  masses  of  necrotic  tissue  were  lying  loose  in  the  ulceration  ;  the 
odor  was  indescribably  offensive  ;  the  child  lay  quiet  and  sonmolcnt 
unless  aroused,  and  then  shrieked  and  tossed  al)out  in  angry  delirium  ; 
the  pulse  was  130  and  feeble,  tlie  i'esj)iration  about  25,  temperature 
102^ij°  F. ;  the  skin  around  the  ulceration  was  swollen  and  reddened. 
In  spite  of  energetic  treatment  the  gangrene  extended  without  the 
slightest  check,  and  in  two  days  the  cavities  of  the  nose  and  mouth  were 
both,  exposed  and  the  palate  was  gone  ;  in  another  the  lower  o'velid  had 
fallen  away  from  the  upper  by  the  detachment  of  its  inner  eonuuissure ; 
a  large  part  of  both  jaws  was  denuded  of  periosteum  at  the  bottom  of 
the  ulceration,  and  the  bones  themselves  were  already  necrotic.  The 
pulse  was  about  140,  the  respiration  about  40,  the  temperature  varying 
from  101°  to  104°  F.  On  the  fourth  day  after  admission  the  morning 
temperature  was  104j*o°  F.,  the  afternooii  9d^^°  F.  She  died  on  the 
fifth  day  after  admission,  about  the  fourteenth  day  from  the  invasion 
of  the  tissues  by  the  bacteria.  This  extensive  destruction  by  gangrene 
of  all  the  tissues,  the  blood-supply  not  beiaig  cut  off,  is  exceptional  and 
only  found  in  similar  conditions ;  it  woidd  seem  that  young  tissues, 
especially  when  reduced  by  debilitating  illness,  afford  the  most  favor- 
able soil  possible  for  the  growth  of  these  micro-organisms ;  or,  jierhaps 
it  is  the  same  thing  to  sa}',  have  no  power  of  resistance  to  their  growth. 

Multiple  peripheral  neuritis  has  been  mentioned  as  the  result  of  sep- 
ticsemia.  One  well-marked  case  occurred  under  my  observation  in  the 
person  of  a  professional  colleague  who  wounded  himself  in  the  hand  at 
an  operation  for  the  opening  of  a  phlegmonous  cellulitis.  The  resulting 
inflammation  was  of  decided  severity,  but  not  extreme,  and  after  a|)parent 
recovery,  having  resumed  practice,  he  exjierieneed  a  gradual  loss  of 
power  with  pain  along  the  nerve-trunks,  first  in  the  arm  which  had  been 
the  seat  of  the  injury,  but  gradually  invading  both  upper  and  lower 
extremities.  It  lasted  nearly  a  month,  and  gradually  disappeared,  the 
recovery  being  comjjlete.' 

Gussenbaur's  definition  of  septicaemia,  which  I  have  adopted,  fixes 
no  definite  period  of  time  for  the  termination  of  the  disease,  but  the 
course  as  described  is  essentially  acute.  It  is  usually  a  matter  of  l)ut 
a  few  days  before  death  closes  the  scene  or  convalescence  is  established, 
or,  pus  forming,  the  subsequent  course  is  claimed  to  transfer  it  into  a 
pyaemia  of  one  form  or  another.  It  has  seemed  to  me,  however,  that  if 
in  a  certain — and  that  not  infrequent — number  of  cases  the  acute  nervous 
symptoms  subside  and  pus  in  moderate  amount  apjiears,  the  character  and 
persistence  of  the  febrile  movement  justify  us  in  regarding  the  condition 
as  chronic.  It  is  a  continuous  fever,  with  about  the  diurnal  variation  that 
belongs  to  health,  but  is  from  one  to  two  degrees  higher.  The  tempera- 
ture, instead  of  running  along  between  98°  and  99°  F.,  runs  between  99° 
and  100°  F.  or  100°  and  101°  F.,  with,  occasionally,  a  rise  of  a  degree 
or  a  fraction  of  a  degree  more,  but  seldom  falling  below  ;  not  presenting 
the  characteristic  features  of  the  pyaemic  chart,  of  great  diurnal  varia- 

'  Consult  Dr.  J.  J.  Putn.im  :  "  Pathology  and  Etiology  of  Infectious  Processes  on  the 
Nervous  System,"  Transactions  of  TIdrd  Triennial  Congress  of  American  Physicians  and  Sur- 
geons, vol.  iii.,  1894. 


SEPTICEMIA.  393 

tions,  but  keeping  the  surgeon  always  anxious  lest  this  sh(iuld  develop. 
This  condition  will  sometimes  last  for  weeks :  every  hosintal  surgeon 
must  recognize  the  clinical  description.  I  am  unaware  of  any  i)ac- 
teriological  observations  having  been  made  to  establish  the  patiiological 
condition  behind  it,  but  when  we  recognize  that  the  occasional  sudden 
accessions  of  temperature  are  always  to  be  referred  to  some  circumstance 
having  to  do  with  an  increase  in  the  production  of  the  jitomaines  of 
putrefaction,  as  by  a  remission  of  strict  antiseptic  treatment,  intentional 
or  otherwise,  and  that  when  this  is  re-established  the  temperature  returns 
to  its  former,  but  still  abnormally  elevated,  degree,  luitil  recovery  is 
brought  about  by  the  curative  processes  of  nature,  the  inference  seems 
justitied. 

It  may  be  urged  that  I  am  here  giving  anotlu'r  name  to  irritative 
fever.  I  prefer  to  give  these  cases  a  pathological  rather  than  a  purely 
theoretical  classitication. 

The  prognosis  of  scpticjemia,  like  that  of  other  acute  infectious  dis- 
eases, depends  more  upon  the  strength  of  the  individual  than  upon  any- 
thing else.  There  are  two  points,  however,  to  be  considered  in  this 
relation  :  the  power  of  resistance  of  the  tissues  to  the  invasion  of  the 
micro-organisms,  as  shown  by  the  rajiidity  of  extension  of  the  local 
process,  and  the  amoiuit  of  systemic  disturbance  which  the  individual 
suifers,  as  shown  in  the  force  and  frequency  of  the  heart's  action.  Single 
observations  of  temperature,  even  though  high,  are  not  of  much  import- 
ance in  a  prognostic  point  of  view,  but  a  continuously  high  fever  has^  a 
bad  outlook  always.  Age  is  an  imjjortant  factor,  the  very  young  and  the 
aged  witlistanding  the  effects  of  septic  fever  and  intoxication  but  poorly; 
and  it  goes  without  saying  that  any  complicati(jn  of  septic  infection  occur- 
ring in  ])ersons  already  reduced  by  organic  affection  of  an  internal  organ, 
be  it  kidneys,  lungs,  or  heart,  is  of  the  gravest  prognosis. 

Other  tilings  being  equal  also,  the  prognosis  is  greatly  influenced  by 
the  promptitude  and  thoroughness  of  the  ti'catment.  The  inaugura- 
tion of  an  active  antisejitic  treatment,  though  the  temperature  be  very 
high,  M'ill  usually  i)e  followed  by  a  remission  if  undertaken  before  ner- 
vous symptoms  become  severe. 

The  treatment  of  septicaemia  must  have  I'clation  to  prophylaxis  as 
well-as  to  the  later  manifestations  shown  in  the  general  condition.  In 
the  early  stages  it  is  mainly  local,  and  means  the  application  of  all  the 
rules  and  remedies  of  the  so-called  autisejitic  surgery  of  to-day  ;  in  the 
later  period,  when  the  heart  threatens  to  give  out,  or  the  intestinal  tract 
becomes  irritable,  or  the  brain  is  oppressed  by  the  presence  of  a  poison, 
the  specific  treatment  of  the  disease,  the  antisepsis,  becomes  subordinate 
to  that  directed  to  overcoming  these  c(mditions  of  the  general  system. 
The  projihylaxis  of  septicsemia,  however,  belongs  to  another  subject ;  it  is 
included  in  the  treatment  of  all  wounds,  whether  operative  or  otherwise  ; 
it  has  to  do  with  the  jireparation  of  the  patient  for  an  operation — the 
operating-room,  the  instruments,  dressings,  the  operating  held,  the  per- 
sonal cleanliness  and  disinfection  of  the  surgeon  and  attendants  of  every 
grade,  or,  when  these  are  not  at  hand  as  in  a  well-regulated  hospital,  to 
aim  for  them  as  far  as  possible,  supplementing  them,  however,  with 
remedies  having  in  view  the  destruction  of  infectious  substances  which 
may  have  gained  access  to  the  wound  before  the  care  of  the  surgeon  is 


394  SEPTICAEMIA,  PYJEMIA,  AND  POISONED   WOUNDS. 

given  it.  It  would,  however,  involve  a  repetition  if  these  matters  were 
given  at  length  here  ;  they  will  be  treated  of  under  the  aseptic  treat- 
ment of  wounds.  We  have  here  to  speak  only  of  the  treatment  of 
wounds  whieh  have  become  infected  :  wliether  this  be  from  the  fault 
of  the  surgeon  in  not  having  achieved  the  desired  asepsis,  or  from  the 
nature  of  the  accident  and  its  surroundings,  is  indifferent;  its  existence 
is  determined  when  the  conditions  heretofore  described  are  foinid. 

If  the  wound  has  become  infected,  the  treatment  is  started  antisep- 
tically  at  once.  The  two  princijial  methods  are  the  dry  and  the  moist. 
The  first  is  founded  on  the  well-known  fact  that  the  development  of 
bacteria  requires  heat  and  moisture  :  if  either  of  these  be  absent — /.  e.  if 
the  temperature  be  near  the  freezing-jjoint  or  if  the  parts  be  absolutely 
dry — no  putrefaction  can  take  place.  The  first  of  these  conditions  is, 
for  obvious  reasons,  impossible  of  fulfilment,  but  the  latter,  if  the 
wound  be  not  very  large  or  ragged,  may  be  approximately,  often  suf- 
ficiently, achieved  by  the  employment  of  materials  of  various  kinds 
which  will  absorb  the  discharges  of  the  wound  and  A\ith  that  sterilize 
the  soil  in  which  the  micro-organisms  breed.  Iodoform,  l)oric  acid,  bis- 
muth, inditferent  substances,  as  starch,  lycopodium,  have  this  in  common, 
and  when  freely  applied  with  a  thick  sterilized  dressing,  as  gauze,  dried 
moss,  jute,  oakum,  or  even  absorbent  cotton,  over  them,  \\ill  occasionally 
serve  this  })urpose.  The  application  of  this  method  is,  however,  limited  : 
it  requires  that  the  wound  shduld  be  fairly  smooth,  with  a  minimum  of 
ragged  edges  or  exposure  of  smiace,  and  that  the  secretion  should  not  be 
very  abundant :  this  occurs  only  in  quite  recent  Avounds. 

When  the  wound  is  extensive,  not  capable  of  nearly  complete  closure, 
has  a  quantity  of  ragged  edges  and  exposed  muscles,  with  the  intermus- 
cular spaces  and  connective  tissue  leading  along  the  vessel-sheaths  laid 
bare,  in  every  one  of  \\hich  the  secretions  of  the  wound  collect  and 
serve  as  fertile  breeding-grounds  for  the  bacteria,  it  is  necessary  that 
some  means  be  employed  either  to  remove  them  or  to  destroy  the  germs 
and  their  spores  in  situ.  For  this  purpose  various  antiseptic  solu- 
tions are  employed  in  many  different  methods  to  suit  exigencies  and  to 
meet  mechanical  difHculties  of  situation,  etc.  There  are  three  princij)al 
methods  of  applying  the  moist  dressings  :  first,  intermittent  washing  of 
more  or  less  frequency ;  second,  constant  irrigation  ;  tiiird,  application 
of  dressings  wrung  out  in  various  solutions  or  combinations  of  these 
solutions.  Appreciating  the  importance  of  rest  in  every  healing  wound, 
as  little  disturbance  as  is  consistent  with  the  thorough  removal  of  the 
infectious  matter  should  be  employed  :  we  judge  of  the  thoroughness  of 
the  removal  by  the  effect  on  the  temperature.  The  washing  is  done 
most  conveniently  with  a  so-called  fountain  syringe  or  irrigating  bottle 
suspended  above  the  level  of  the  wound,  to  get  the  amount  of  force 
required  to  inject  the  washing  fluid  into  all  the  interstices  of  the  wound, 
using  best  a  glass  point  for  ct)ntact  with  the  wound  (in  a  hospital  a  sepa- 
rate point  is  kept  for  each  patient),  which  in  the  intervals  between  use  is 
kept  in  an  antiseptic  solution. 

As  warm  water  is  usually  more  grateful  to  the  jiatient's  feelings  than 
cold,  it  is  in  most  cases  best  to  use  it ;  there  are  cases,  however,  when  the 
j)utrefaction  is  active,  in  which  the  inhibiting  efl^ects  of  cold  on  the  devel- 
opment of  the  micro-organisms  may  be  tried  with  advantage,  especially 


SEPTICEMIA.  395 

if  the  bodily  temperature  be  high,  inasmuch  as  by  reducing  this  we  are 
restricting  the  activity  of  their  reproduction.  Having  regard,  tlien,  to 
the  temperature,  the  wound  may  be  washed  off  with  simply  sterilized 
water ;  with  a  solution  of  carbolic  acid  from  1  to  5  per  cent. ;  with  mer- 
curic bichloride  of  from  1  :  500  to  1  :  20,000 ;  with  potassium  perman- 
ganate of  from  1  to  10  per  cent. ;  with  hydrogen  peroxide  of  from  1  : 1 
or  from  that  to  1  :  15  ;  with  Tiiicrsch's  solution ' — according  to  the  effect 
to  be  produced  as  shown  by  the  odor  and  the  degree  of  temperature.  This 
is  but  a  small  list  of  the  remedies  recommended  :  tliey  are,  lH)wever, 
those  in  principal  use,  having  stood  the  test  of  practical  applications 
in  many  different  hands  and  under  various  conditions.  As  to  a  choice 
between  them,  one  is  guided  by  idiosyncrasies  of  individuals  and 
the  effect  on  the  tissues.  CJarbolic  acid  produces  an  unpleasant  anses- 
thetic  effect  on  the  part  if  allowed  to  remain  in  contact  witii  it  long  or 
if  used  in  sufficient  strength  to  be  a  germicide.  JMercurie  bichloride 
is  the  best  germicide,  but  acts  unfavorably  upon  the  tissues  themselves, 
and  there  is  always  the  further  danger  of  sidivation  if  used  freely. 
Potassium  permanganate  is  expensive  and  stains  everytliing  with  which 
it  comes  in  contact,  whereby  the  local  process  is  hidden  and  one  is  at  a 
loss  to  know  what  is  going  on  in  the  wound  ;  indeed,  later  investigations 
seem  to  show  also  that  its  disinfectant  properties  at  least  have  been  over- 
rated. Hydi'ogen  peroxide,  which  has  been  extensively  advertised  and 
lauded  to  an  extent  in  some  quarters  that  renders  one  suspicious,  has 
very  decided  objections :  it  is  expensive,  is  extremely  uncertain  in 
quality  of  manui'acturc,  requires  particular  care  for  its  preservation, 
and  if  used  I'reely  will  salivate.  For  these  reasons  it  is  not  adaptable 
for  ordinary  use.  Taking  it  altogether,  mercuric  bichloride  meets  the 
indications  for  practical  use  the  best,  though  it  requires  care  about  the  sick- 
room in  that  tiiere  is  nothing  in  its  appearance  or  smell  to  distinguish  a 
solution  of  it  from  water.  Pharmacists  have  met  the  demand  for  its  use  by 
preparing  tal)lets  combined  witii  ammonium  (or  sodium)  cidoride  of 
definite  strength,  one  of  which,  dissolved  in  a  ])int  of  water,  makes  a 
solution  of  1  :  500,  and  with  this  as  a  standard  the  strength  may  be  varied 
according  to  the  indications.  In  order  to  identify  the  solution,  tablets 
are  occasionally  colored  with  some  indifferent  coloring  matter.  In  the 
hands  of  the  laity  this  may  be  a  wise  precaution,  but  the  solution  is 
disagreeable  to  work  witli,  to  say  the  least. 

In  case  of  extensive  laceration  of  skin  and  more  or  less  exposure  of 
underlying  tissues,  where  a  loss  by  slough  is  inevitable,  and  where, 
under  ordinary  circumstances,  the  slougiiing  process  would  surely  be 
accompanied  by  a  septic  process  of  considerable  if  not  dangerous  inten- 
sity, where  the  prac'tical  indication  is  tlie  apjdication  of  a  poultice  to 
hasten  the  process  of  separation,  my  practice  is  to  ajiply  a  thick  layer 
of  cotton  or  jute  or  mixed  tissue  freely  wetted  \vith  a  hot  solution  of 
mercuric  bichloride  of  about  1  :  4000,  covered  with  a  rubber  clotii  or 
oiled  silk  to  keep  it  from  drying  ;  this,  which  I  call  an  antiseptic  poultice, 
is  changed  every  few  iiours  (dej)ending  upon  the  urgency  and  the  effect 
produced)  by  rinsing  the  dressing  oil'  by  wringing  it  out  once  or  twice 
with  a  fresh  solution,  and  is  again  ajiplied  hot.  By  this  means  I  am 
frequently  able  to  treat  an  extensive  slougiiing  process  with  little  or  no 
^  Salicylic  acid,  2  ;  boric  acid,  12  ;  boiling  water,  1000  :  jiarts  by  weight. 


396  SEPTICEMIA,  PYJEMIA,  AND  POISONED    WOUNDS. 

febrile  movement.  A  cnsc!  in  point  occurred  in  a  man  the  bottom  of 
whose  foot  had  been  ahnost  torn  oil'  in  a  "planer,"  the  injury  being 
very  similar  to  the  one  above  cited  of  f/ciiif/rene  fond roy ante,  but  in 
which  I  was  able  within  a  few  hours  to  institute  the  treatment  above 
described,  and,  although  the  suppurating  process  lasted  several  weeks,  it 
was  throughout  its  course  absohitely  odorless  and  afebrile.  This  ex- 
tremely favoral)le  course,  however,  is  jtossible  only  when  tlie  treatment 
is  instituted  early,  bclbrc  the  septic  j)roccss  has  l)egun  :  it  is  really  asep- 
tic treatment,  and  not  the  treatment  of  sei)tic:cmia.  It  shows,  however, 
what  may  be  accomplished  by  that  method  of  treatment,  for  frequently 
Avhen  the  septic  process  is  already  in  full  swing  the  ap|)lication  of  an 
antiscpti(>  poultice  as  described  will  reduce  the  activity  of  the  process  or 
stop  it  altogether.  If  it  does  not,  the  dressing  may  be  removed  every 
two  or  three  hours,  the  wound  thorougldy  ^vashed  out  in  every  part 
of  the  interstices  with  a  solution  of  1  :  2(J(X),  and  the  poultice  reapplied, 
carrying  it  well  up  to  above  the  limit  of  the  wound.  In  severe  cases  a 
more  frequent  change  is  required,  and  the  solution  should  be  allowed  to 
drip  constantly  over  the  dressing,  provision  being  made  to  carry  it  off: 
in  aggravated  cases  a  stream  of  the  solution  may  be  arranged  to  play 
constantiv  over  the  wound,  at  once  disinfecting  it  and  washing  the  loose 
and  soluble  products  of  decomjjosition  away.  This  constant  irrigation, 
however,  requires  caution,  as  it  may  salivate,  and  it  should  therefore  not 
be  used  in  greater  strength  than  1  :  10,000  for  any  length  of  time.  I 
sometimes  alternate  the  washing  off  of  the  wound  with  the  solution 
once  in  two  or  three  hours,  with  irrigation  of  sterilized  water  to  wash 
away  whatever  sublimate  may  have  remained  on  the  surface  or  in  the 
interstices  of  the  tissues.  Depending,  hence,  upon  the  temperature  and 
the  local  swellings,  the  strength  and  the  length  of  time  of  the  appli- 
cation are  to  be  judged,  varying  from  intermittent  washings  of  sterilized 
water  to  constant  irrigation  with  a  sublimate  solution. 

The  entire  submersion  of  an  extremity  in  an  antiseptic  solution  is 
practised  in  some  cases  when  the  laceration  is  extreme  and  the  mechan- 
ical ditticidties  in  the  way  of  a  thorough  irrigation  cannot  be  otherwise 
overcome.  Following  the  practice  first  observed  at  the  Massachusetts 
General  Hospital,  I  have  used  the  coal-tar  product  of  sulphonaphthol 
in  the  proportions  of  from  1  to  5  per  cent.,  the  usual  strength  being  2 
per  cent.  The  limb  is  kept  innnersed  in  this  solution  for  a  few  hours, 
the  moist  dressing  sul)stitutcd,  and,  if  the  temperature  rises,  the  limb  is 
reimmersed  :  I  have  used  this  quite  siitisfactorily  in  cases  already  septic 
when  admitted  to  the  hosjiital.  The  objection  to  it  is  a  liability  to  pro- 
duce dermatitis  of  the  healthy  skin  above  the  seat  of  the  injury,  and  a 
shininess  of  the  surfiice  where  the  moisture,  which  bears  a  certain  re- 
semblance to  an  emulsion,  comes  in  contact  with  the  raw  surface. 
Patients,  however,  usually  express  themselves  as  relieved  from  pain  in 
a  short  time.     "  Creolin  "  may  be  used  in  the  same  way. 

Incisions  through  the  skin  into  the  swollen  tissues  to  allow  the  escape 
of  the  infiltrated  serum  serve  also  as  avenues  through  which  the  solution 
may  be  injected  into  the  tissues  where  the  products  of  putrefaction  are 
developing  :  these  incisions  often  require  to  be  numerous  and  deep,  and 
are  frequently  the  means  of  saving  a  limb  or  life  that  otherwise  would 
be  sacrificed. 


SEPTICEMIA.  397 

In  septic  lymphangitis  and  adenitis  it  is  sometimes  also  necessary  to 
dissect  out  tlie  contents  of  tlie  axilla  or  groin,  whicli  have  become  foci 
from  which  the  septic  process  is  further  distributed.  Unfortunately, 
however,  none  of  these  precautions  or  remedies  is  suflticient  to  clieck  the 
onward  course  of  the  disease :  the  piilegnionous  process  extends  near 
and  nearer  the  trunk ;  more  and  more  of  the  limb  becomes  gangrenous ; 
the  fever  becomes  woi'se,  the  brain  symptoms  more  pronounced ;  it  is 
evident  that  unless  the  patient  is  relieved  from  the  continued  absorption 
of  the  putrefactive  products  death  will  ensue.  Under  these  circumstances 
the  removal  of  the  whole  limb  is  an  imperative  necessity,  and  witli  it 
comes  the  decision  of  the  seat  of  the  amputation.  Will  it  do  to  operate 
through  soft  tissues  already  infiltrated  witli  the  products  of  decomposi- 
tion, or  must  the  whole  limb  be  sacrificed,  adding  to  the  dangers  of  tlie 
operation,  already  very  great?  While  such  a  thing  is  of  course  undesir- 
alilc  per  sc,  and,  other  tilings  being  equal,  is  to  be  avoided,  yet  operation 
through  infiltrated  tissues  is  not  absolutely  forbidden.  It  depends  upon 
the  character  and  extent  of  tlie  septic  ])rocess.  One  cannot  advise  cutting 
through  a  gangrenous  tissue  or  one  in  the  immediate  neighborhood  thereof, 
but  I  have  repeatedly,  under  stress  of  circumstances,  amputated  in  regions 
where  the  tissues  were  infiltrated  and  discolored,  and  witli  care  have  had 
recovery.  I  have  in  mind  a  man  who  was  cut  on  the  foot  with  an  axe 
wliich  passed  deeply  lietween  tlie  great  and  second  metatarsal  bones  ^\'itll- 
out  injuring  either,  but  in  whom  the  \vound  b(!came  infected  :  gangrene 
appeared  in  isolated  spots  on  the  leg  above  the  ankle  ;  tiie  jiatient's  gen- 
eral condition  became  exceedingly  bad — could  hardly  be  worse  ;  pulse 
and  temperature  both  high,  and,  quite  incapable  of  appreciating  his 
condition,  he  lay  in  a  muttering  delirium.  The  local  a])pearances  grew 
worse,  tlie  gangrenous  spots  appeared  aliout  the  knee,  and  in  desperation 
amputation  was  performed  at  about  the  junction  of  tiie  middle  and  U])j)er 
thirds  of  the  leg  as  the  highest  point  at  which  it  was  believed  he  would 
survive  the  shock  of  operation.  He  was  so  torpid  by  the  eifect  of  the 
poison  on  his  brain  that  he  required  almost  no  ether  ;  he  was  unconscious 
of  tiie  operation  for  several  days  after  it  was  over.  The  cut  surface 
hardly  bled ;  it  was  discolored  and  dirty  with  sanguineous  serum ;  the 
arteries  were  occluded.  There  was  no  odor  to  the  Jreshli/-cut  surface  or 
stump  aftertcard.  There  was  no  union  by  first  intention,  the  skin-flaps 
became  gangrenous  along  their  edges,  and  yet  the  patient  in  time  got 
well  with  a  useful  stump.  This  was  an  extreme  case,  and  very  doubtful 
in  progress  for  a  long  time,  but  the  end  justified  the  rislv ;  and,  as  less 
severe  cases  have  also  recovered,  it  can  be  claimed  that  while  the  practise 
is  not  desirable  as  a  rule,  it  is  sometimes  good  surgery. 

An  elevated  position  to  the  aftccted  limb,  if  it  be  such,  is  most  desira- 
ble, and  the  importance  of  rest  in  keeping  the  circulation  as  inactive  as 
practicable  is  not  to  be  forgotten  ;  therefore  the  suspension  of  an  arm 
or  leg  is  to  be  practised  if  possible. 

As  to  the  treatment  of  the  constitutional  complications  which  occa- 
sionally arise,  we  are  guided  by  general  principles.  The  disease  is  from 
the  beginning  depressing,  as  shown  in  the  lieart's  action  ;  stimulants  of 
all  kinds  are  therefore  allowable,  the  choice  being  left  to  the  taste  of  the 
individual  (surgeon).  The  necessity  and  the  amount  required  are  indicated 
quite  as  much  by  the  dryness  or  otherwise  of  tlie  tongue  as  by  anything 


398  SEPTICAEMIA,  rV.EMIA,  AXI>  POISONED    WOUNDS. 

else,  thougli  the  state  of  the  jHiLse  of  course  is  to  be  considered.  Brandy, 
St.  Croix  rum,  B(inrhon  whiskey,  in  about  the  order  mentioned,  witii  tiie 
bitter  tonics  of  cinciiona  and  gentian,  are  the  most  desirabk'.  If  tiie 
patient  can  take  milk,  this  in  the  form  of  millv-])uneh  and  egg-nog 
gives  nourishment  with  the  stimulation;  if  there  l)e  vomiting,  "ginger 
ale,"  champagne,  and  carbonated  water  will  frequently  control  it,  and  I 
have  known  fresh  buttermilk  to  be  retained  wiien  every  other  form  of 
nourishment  was  rejected.  Other  forms  of  intestinal  disturbance,  as  diar- 
rli(pa,  are  to  be  treated  by  the  ordinaiy  astringent  and  sedative  remedies 
of  acetate  of  lead,  opium,  catechu,  tannin,  etc.  I  iiave  sometimes  thought 
that  good  results  in  the  beginning  of  an  attack  followed  tiie  admin- 
istration of  a  brisk  saline  cathartic,  wiiich  ap])ears  to  reliexe  some  of 
the  toxic  symptoms,  and  the  opium  is  then  better  bcn'ne.  When  a  diar- 
rhoea occurs,  it  is  best  to  stop  the  use  of  the  mercuric  bichloride  and 
substitute  something  ha^'ing  less  tendency  toward  intestinal  irritation. 
If  the  diarriicea  becomes  dysenteric  in  ciiaracter,  euemata  of  opium  and 
starch  and  lead  will  frequently  stop  it.  Great  care  must  be  taken  in  the 
nursing  of  patients  in  the  severe  cases,  as  the  stupor  is  so  great  that  the 
skin  over  prominent  points  becomes  ulcerated,  and  bed-sores  of  great 
extent  and  obstinacy  result.  This  is  especially  tiie  case  when  the  urine 
and  freces  are  discharged  involuntarily.  Tiie  patient  should,  if  possible, 
lie  upon  an  air-  (or  water-)  bed,  or,  if  that  is  unattainable,  air-cushions 
and  ring-pads,  to  take  tlie  pressure  from  the  threatened  jioints,  and,  above 
everything  else,  the  most  constant,  unremitting  attention  must  be  given 
to  keeping  the  patient  clean  and  dry.  Use  frequent  bathing  with  alco- 
hol or  cologne,  dusting  zinc  powder  or  starch  or  lycopodium  upon  the 
parts  afterward,  and  ciiange  the  ])osition  from  back  to  side  and  from 
side  to  side  as  much  as  the  proper  treatment  of  the  local  disease  will 
permit.  It  must  be  remembered  that  the  disease  is  most  exhausting,  and 
convalescence  is  correspondingly  slow. 

Pyemia. 

A  secondary  fever  with  certain  constant  characteristic  diurnal  feat- 
ures, coming  on  in  tiie  course  of  the  healing  of  a  wound  by  suppura- 
tion, has  been  known  since  the  earliest  medical  writings.  In  the  wars 
of  the  Middle  Ages  epidemics  of  such  a  fever  attracted  the  attention  of 
Ambrose  Pare  and  of  Paracelsus.  The  former  noticed  that  fractures 
of  the  liones  of  the  skull  by  sabre  cuts,  etc.  were  followed  by  abscesses 
of  the  liver  ;  Paracelsus,  that  the  fever  was  intermittent,  commenced 
with  a  chill,  and  was  frequently  accompanied  by  inflammation  of,  and 
purulent  deposits  in,  the  joints.  Morgagni  described  the  abscesses  as 
metastatic,  and  stated  that  the  pus  was  carried  to  various  internal  organs 
— tlie  lungs,  liver,  spleen,  etc. — and  tliere  dept)sited  from  the  blood-ves- 
sels ;  he  described  an  exudation  into  tiie  pleura  also  as  the  result  of  puru- 
lent absor]ition  from  a  wound.  Tiie  intermittent  tyjie  of  the  fever  and  its 
epidemic  ciiaracter  led  to  the  opinion  that  it  was  of  miasmatic  origin.  Mod- 
ern research,  however,  especially  Vircliow's  investigations  on  embolism 
and  thrombosis,  the  experiments  of  Billroth  and  Otto  Weber,  and  finally 
those  of  Robert  Koch  on  the  traumatic  infective  fevers,  demonstrated 
that  we  have  to  do  with  the  absorption  of  pus  infected  with  micro-organ- 


PY^JIIA.  399 

isms ;  and  the  definitiou  of  Gussenbaur  is  now  regarded  as  correct — viz. 
pyismia,  or  purulent  fever,  is  "  a  general  infective  disease  which  arises 
from  the  entrance  into  the  blood  of  the  constituents  of  infected  pus.  It 
is  distinguished  from  other  septic  infective  diseases  by  the  development 
of  multiple  abscesses  in  various  organs,  and  by  an  intermittent  fever."  ' 

A  pre-existing  supjjuration,  which  implies  a  process  of  several  days' 
or  weeks'  duration  as  the  source  from  which  the  infected  pus  is  derived, 
is  the  almost  constant  rule  in  pyajmia,  though  there  are  exceptional  cases 
in  which  the  injury — not  always  an  open  wound,  even — and  the  general 
infection  run  a  sinudtaneous  course,  with  the  general  symptoms  of  a 
septic;emia  rather  than  those  to  be  described  as  characterizing  pytemia, 
but  where  the  autopsy  discloses  the  presence  of  metastatic  abscesses  and 
purulent  exudations.  There  are  others,  again,  in  which  the  original  wound 
has  healed,  but  the  general  disease  has  afterward  occurred,  running  to  a 
fatal  termination,  mIicu  the  autopsy  again  shows  multiple  abscesses  and 
purulent  exudations  in  the  serous  cavities  and  joints. 

Making  the  post-mortem  appearances  the  diagnostic  criterion,  we  learn 
that  pyffiuiia  may  occur  as  either  a  primary  or  a  secondary  fever — that 
there  may  also  be  a  period  of  incubation  after  the  reception  of  the 
injuiy,  with  no  general  or  local  symptoms,  during  which  the  infection 
is,  so  to  speak,  working  like  an  exanthematous  fever,  the  general  disease 
breaking  out  subse((uently  and  running  its  course  indejK'ndently  of  the 
original  injury,  ^\'hen  venesection  was  a  more  frequent  j)ractice  such 
cases  occurred  more  often  than  they  now  do. 

Pyaemia  may  run  an  acute  or  a  chronic  course,  more  frequently  the 
former,  death  occurring  in  the  course  of  from  five  to  fifteen  days  ;  it 
may,  however,  last  many  months.  It  must  be  understood,  at  the  same 
time,  that  the  division  is  principally  clinical ;  the  pathology  is  the  same — 
viz.  the  entrance  into  the  blood  of  the  elements  of  infected  pus ;  and 
this  differentiation  has  to  do,  first,  with  the  amount  taken  up  at  any  one 
time,  and,  second,  with  the  power  of  the  individual  to  M'ithstand  the  in- 
fection. An  attack  of  acute  pyaemia  may,  though  it  is  unusual,  subside 
into  a  chronic  course,  and,  rice  i-ersd,  one  that  has  been  pursuing  a  chronic 
course  may  quite  unexpectedly  become  acute. 

The  course  of  a  typical  case  of  pyaemia  is,  in  general,  that  at  a  \'ari- 
able  period  after  suppuration  has  been  established,  the  wound  granulating 
and  the  dischai'ge  creamy,  in  all  respects  the  M'ound  pursuing  a  normal 
course,  the  patient  has  a  chill — variable  in  intensity  from  a  crawling 
along  the  back  to  the  teeth  chattering  and  the  extremities  shaking, 
in  difi'crent  cases  also  lasting  variably  from  a  few  minutes  to  an  hour 
or  more.  This  is  followed,  sometimes  accompanied,  by  an  increase  of 
temperature,  which  may  rise  two  or  three  or  even  more  degrees,  fall- 
ing to  normal  or  below  the  -next  morning.  This  succession  of  chill 
and  fever,  with  morning  remission,  may  occur  daily  or  every  other  day, 
and  the  likeness  to  malarial  fever  becomes  marked.  Along  with 
the  febrile  movement  there  is  a  condition  of  general  malaise — loss  of 
ap])etite,  thirst,  and  headache,  with  some  sleeplessness ;  the  patient  is 
quite  aware  that  he  is  not  so  well,  and,  if  he  be  from  or  in  a  malarial 
district,  will  himself  insist  that  he  is  suffering  from  malaria,  the  sub- 
jective symptoms  are  so  identical.     At  the  same  time,  or  perhaps  ante- 

'  Op.  cit.,  p.  158. 


400  SEPTICEMIA,  PYJEMIA,  AND  POISONED   WOUNDS. 

cedent  to  the  febrile  movement,  the  wound  indicates  that  something 
has  taken  place  to  interfere  with  the  healing  process.  The  suppuration 
ceases ;  the  granulations  become  ]iale  and  ilabby,  and  may  break  down 
entirely,  leaving  the  wound  with  a  thin,  dirty,  sanious  discharge ;  the 
edges  of  the  wound  becc>me  swollen  and  (edematous ;  frequently  we  are 
able  to  detect  cord-like  swellings  along  the  course  of  the  larger  veins 
leading  from  the  j^art :  these  are  hard  and  tender  to  the  touch,  and  may 
extend  some  distance  up  the  limb  toward  the  trunk.  The  limb  will  soon 
after  swell  in  its  whole  extent,  the  prominences  and  depressions  become 
obliterated,  and  the  natural  configuration  of  the  limb  quite  lost. 

The  repetition  of  the  chills  and  febrile  movement  continues  with 
greater  intensity,  frecpiency,  and  irregularity ;  the  alternations  with 
subnormal  temperature  are  more  marked,  falling  sometimes  to  95°  F. 
or  less,  only  to  rise  in  a  few  hours  to  perhaps  over  104°  F.  This  great 
range,  repeating  itself  for  several  days,  irregular  as  to  the  time  of  day, 
is  a  striking  feature  found  in  almost  no  other  condition.  The  patient 
emaciates  rapidly,  the  tliirst  increases,  the  appetite  fails,  the  tongue 
becomes  red  and  dry,  the  skin,  alternately  bathed  in  sweat  or  abnor- 
mally dry,  is  apt  to  become  yellowish  in  color,  due  not  so  much  to  inter- 
ference with  the  function  of  the  liver  as  to  a  change  in  the  blood  itself, 
the  coloring  matter  being  liberated  [lufmator/enous  ictcrua)  by  destruction 
of  the  red  blood-corpuscles ;  the  pulse  increases  in  frequency  and  be- 
comes weaker.  In  contradistinction  to  septicaemia,  the  mind  is  not  often 
affected  ;  instead  of  Ijeing  apathetic  and  somnolent,  the  patient  is  con- 
scious of  his  weakened  condition,  often  wakeful,  and  annoyed  by  lights 
or  sounds,  and  likely  to  be  querulous  and  complaining.  In  cases  which 
run  a  protracted  course  the  breath  frequently  exhales  a  peculiar  mawk- 
ishly sweet  odor,  compared  sometimes  to  newly-mown  hay,  and  the 
patient  complains  of  a  disagreeable  taste  always  present.  As  the  disease 
progresses  secondary  involvement  of  distant  organs  or  parts  becomes 
evident ;  the  patient  complains  of  pain  in  moving  some  particular  and 
usually  distant  joints  :  it  simulates  rheumatism  at  first,  and  is  frequently 
mistaken  for  that  disease.  The  joint  is  tender  on  pressure  or  movement, 
red  and  swollen,  but  in  the  course  of  a  few  days  fluctuation  appears,  and  on 
puncturing  or  incising  it  pus  is  found  :  this  condition  may  occur  in  several 
joints  if  the  patient  lives  long  enough.  Other  situations  in  the  extrem- 
ities— the  subcutaneous  connective  tissue,  the  muscular  interspaces,  even 
the  muscles  themselves — are  not  infrequently  the  seat  of  the  metastatic 
abscesses,  and  particular  mention  must  be  given  to  their  occurrence  in 
the  medullary  canals  of  the  bones,  where  they  may  be  undetected  until 
they  have  made  extensive  ravages,  or  be  only  discovered  at  the  autopsy. 
Their  presence  is  to  be  suspected  when  the  patient  complains  of  severe 
pain  in  the  bones  with  exquisite  tenderness  along  the  shafts  :  the  slight- 
est movement  is  agony.  At  first  the  tenderness  is  usually  located  at 
distinct  points,  afterward,  however,  extending  over  the  whole  bone.  At 
first  there  is  not  much  else  than  the  jiain,  Init  later  the  tissues  over  the 
bone  become  oedematous,  and,  if  the  patient  lives  long  enough  unrelieved, 
other  evidences  of  pus  in  redness  and  fiuctuation  become  manifest,  and  by 
incision  the  involvement  of  the  bone  is  shown  in  the  loosening  of  the  peri- 
osteum. Like  the  disease  of  the  joints,  the  resemblance  to  rheumatism 
at  the  outset  is  considerable,  in  both  the  local  and  the  constitutional  symp- 


PY^3IIA.  401 

tomatology  ;  it  is  not  until  latei*  that  tlie  true  condition  becomes  locally 
manifest.  It  is  therefore  necessary  to  be  keenly  on  the  alert  in  the  case 
of  a  suppurating  wound  to  detect  these  evidences  of  transference  to  distant 
parts,  because  if  the  treatment  be  initiated  early  there  is  a  chance  of 
saving-  life  or  limb,  which  chance,  however,  grows  rapidly  less  as  the 
suppuration  extends  through  the  whole  bone.  In  the  beginning  the 
abscesses,  as  in  other  situations,  are  single  or  isolated,  but  they  increase 
in  number  and  run  together  until  the  whole  canal  is  occupied  with  pus. 

Of  other  accessible  organs,  the  secondaiy  abscesses  are  to  be  looked 
for  in  the  jxirotid  and  thyroid  glands,  and  exceptionally  in  the  testicle. 
Metastatic  deposits  in  the  internal  organs  often  go  undetected,  their 
presence  being,  of  course,  by  no  means  so  evident  as  in  the  situations 
mentioned.  Indeed,  the  special  symptomatology  of  abscesses  in  internal 
organs — and  they  may  occur  in  almost  any — is^  not  characteristic  :  in  the 
lungs  there  may  be  cough  and  expectoi'ation,  with  some  dyspnoea,  but  so 
long  as  the  abscesses  are  small  there  is  little  to  judge  from.  With  pleuritic 
exudation,  however,  the  evidences  of  dyspnoea,  with  dulness  on  pressure, 
faintness  or  absence  of  respiration-  and  voice-sounds,  indicate  the  con- 
dition ;  sometimes  there  are  the  other  evidences  of  pleurisy — the  inabil- 
ity to  take  a  long  breath,  difficulty  in  lying  upon  one  side  or  the  other, 
and  increase  in  frequency  of  the  respiration. 

Icterus  is  liable  to  l^e  present  in  metastases  into  the  liver,  but,  as  this 
is  also  present  as  the  result  of  the  destructitin  of  the  red  blood-corpuscles 
in  hajmatogenic  icterus,  tlie  condition  is  not  diagnostic  of  the  metastases 
unless  it  be  associated  with  increased  area  of  liver-dulness  and  localized 
tenderness,  with  possibly  a  tumor  if  the  abscess  become  very  large.  In 
splenic  involvement  the  increased  area  of  dulness  is  almost  the  only 
sign  to  indicate  the  local  trouble,  and  it  is  a  further  source  of  confusion 
if  the  question  of  malaria  comes  up.  The  spleen  is,  however,  one  of  the 
rarer  seats  of  secondary  deposits. 

The  only  case  of  secondary  pysemic  abscess  in  the  muscular  tissue  of 
the  heart  that  I  have  any  knowledge  of  I  saw  at  the  autopsy  of  an 
Italian  laborer  who  died  in  the  New  Haven  Hospital  after  an  illness  of 
nearly  two  months.  This  case  will  be  referred  to  again  in  speaking  of 
the  mixed  form  of  pyosepticsemia. 

We  have  learned  that  a  typical  case  of  pyjemia  consists  clinically  of 
— first,  an  open  suppurating  wound  ;  second,  a  chill;  third,  a  fever  and 
sweat,  these  occurring  irregularly  ;  fourth,  thrombosis ;  fifth,  metastatic 
abscess ;  sixth,  death  in  the  course  of  two  weeks ;  but,  except  the  meta- 
static abscess  or  serous  exudations,  nothing  is  constant.  As  stated  in  the 
beginning,  an  open  suppurating  wound  is  not  an  absolute  or  constant 
feature.  Wunderlich  reports  that  a  young  working-woman  suffering 
with  an  ordinary  'coryza  wet  her  clothes  during  a  hard  day's  work  in 
which  she  perspired  freely.  The  next  morning,  on  getting  up,  she 
became  faint  and  fell,  injuring  her  right  hand.  Recovering  conscious- 
ness, she  was  seized  with  a  heavy  chill  which  lasted  some  time ;  she  had 
pain  in  her  sternum,  headache,  vertigo,  and  diarrhcea.  She  died  on  the 
fourth  day  in  collapse,  having  had  a  continuous  higli  fever  with  erythe- 
matous bulhe  on  both  feet.  The  autopsy  siiowed  a  slight  effusion  of 
blood  in  the  injured  hand ;  the  blebs  on  the  feet  were  filled  with  hem- 
orrhagic pus;  the  joints  of  both  hands  and  feet  were  normal,  as  also  the 

Vol.  1.-26 


402  SEPTICEMIA,  PYJEMIA,  AND  POISONED    WOUNDS. 

vessels  of  the  extremities,  but  tlierc  wei'e  luiiltiplc  abscesses  in  the  thyroid 
gland,  the  liver,  and  the  kidneys,  fresh  extravasation  in  the  brain,  purulent 
myocarditis,  pleuritis,  ledema  of  the  lungs,  and  a  softened  spleen. 

Gussenbaur  reports  the  case  of  a  physician  who  iiad  a  boil  following 
the  examination  of  carcinoma  of  the  uterus  wliieh  healed  vp  completely, 
and  three  weeks  after  h(>  became  ill  with  afternoon  fever,  bronchitis, 
double-sided  empyema,  and  tedema  of  tiie  lungs,  from  which  he  died  on 
the  fourteenth  day.  The  autopsy  revealed,  besides  the  pleural  implica- 
tion, multiple  abscesses  in  the  luugs,  a  large  abscess  in  tiie  liver,  and  a 
softened  spleen. 

Although  the  ciiill  is  by  far  the  most  frequent  inauguration  of  the 
proper  pysemic  process,  every  surgeon  wiio  has  much  to  do  witii  tiie 
disease  recognizes  cases  in  which  it  is  wanting  or  first  appears  after  the 
fever ;  and,  further,  while  the  repetition  of  the  chill  is  the  rule,  it  .some- 
times does  not  reappear  at  all.  Tiiese  variations,  iiowever,  have  no 
appreciable  effect  on  the  course  of  the  disease  nor  on  the  termination. 
Billroth  remarked,  iiowever,  that  disturl)anee  of  tiie  wound  was  very 
apt  to  be  followed  liy  a  chill ;  dressings  of  the  wound,  probings,  and 
reposition  of  fragments  of  broken  bones  were  followed  by  chills  in  the 
course  of  from  two  to  six  hours  ;  it  was  remarkable  how  frequently  the 
morning  and  evening  visits  of  the  surgeon  were  followed  by  chills. 

While  the  type  of  pyemic  fever  is  tiie  intermittent,  this  is  not  abso- 
lute. The  "  pyiEuiic  curve  "  of  the  temperature  cliart  lias  liecii  spoken 
of  as  though  it  were  something  positive  and  pathognomonic,  but  it  has 
just  been  shown  that  the  fever  may  be  continuous,  the  fact  being  that  it 
depends  largely  upon  the  severity  and  rapidity  of  the  infection  as  to 
whether  this  variation  in  the  height  of  the  fever  is  marked  or  not. 

It  also  presents  variations,  even  in  its  intermittence,  wiiich  are  to  be 
noted,  and  which  make  the  diagnosis  doubtful  if  we  depend  upon  the 
chart  alone  to  determine  it.  The  fever  will  sometimes  rise  by  gradual 
steps,  as  between  morning  and  evening,  in  the  course  of  two  or  three 
days,  to  a  considerable  degree,  103°  F.  or  over,  then  fall  either  as  grad- 
ually or  suddenly  to  normal,  giving  rise  to  the  hope  that  the  infection 
has  been  eliminated,  only,  however,  to  repeat  the  process  of  elevation. 
At  anotiier  time  in  the  same  case  tlie  temperature  will  go  suddenly  up 
for  a  day,  and  in  the  next  few  hours  fall  again.  Individual  cases  being 
liable  to  these  striking  variations  from  tlie  type,  little  can  be  judgeil  of 
a  given  case  from  the  chart  alone,  except  that  great  and  repeated  varia- 
tions from  subnormal  to  very  high  tenqierature  after  a  suppurating  wound 
indicate  that  infected  pus  lias  gained  entrance  into  tlie  circulation.  As  an 
instance  of  the  great  variations  in  the  temperature  occurring  in  a  few 
hours,  and  also  of  the  great  irregularity  in  the  course  of  the  fever,  take 
the  accompanying  chart  of  the  course  of  an  acute  pyaemia  in  a  child  of 
about  five  years  of  age,  paralyzed  with  a  spina  bifida,  who  was  admitteil 
with  a  great  bed-sore  alongside  of  and  exposing  the  sacrum  and  coccyx. 
In  spite  of  the  utmost  care  after  admission,  it  extended  deeper,  and  after 
several  months  her  temperature  was  one  day  found  to  be  101°  F.  in 
the  morning,  and  slie  was  feeling  unwell.  The  child  was  too  young  to 
describe  her  sensations,  and  there  was  no  olijcctive  evidence  of  a  chill 
until  later,  but  the  variations  in  the  temperature  began  at  once,  for  on 
the  second  day  it  swung  from  2?>f^°  to  102/^°  (4°),  and  on  the  third 


PY^3IIA. 


403 


day  from  97^°  to  104°  between  5  A.  M.  and  12  m.  (6^°) ;  at  4  p.  m.  it 
had  fallen  to  98°,  only  to  rise  to  105-;^°  at  10  p.  M.  (7^°),  to  fall  the 
next  morning,  the  fonrth  day  of  the  attack,  to  hclow  95°.  As  the  clinical 
thermometer  was  not  graded  below  95°,  it  was  too  low  to  register,  but  it 


Fig.  13. 


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fell  at  least  11°  in  six  hours  :  in  tlie  afternoon  it  rose  to  102 ^%°  (8°). 
On  the  fifth  day  it  oscillated  between  98°  and  103°  at  4  p.  M.  to  104y«^° 
at  9  P.  M.,  and  the  next  moniiu;/,  tlie  sixth  day,  it  was  105^°,  to  fall  in 
the  afternoon  (in  opposition  to  the  rule)  to  98-fL°,  continuing  to  fall  in 
the  morning  of  the  seventii  day  to  be  again  bcloir  95°  ;  it  only  rose  that 
afternoon  to  97^°.  It  continued  to  rise  botli  morning  and  afternoon 
on  the  two  succeeding  days  to  104y\°,  and  without  further  remarkably 
abnormal  variations  siie  died  at  the  end  of  the  eleventh  day.  At  the 
autopsy  it  was  found  that  the  bed-sore  had  cau.sed  a  necrosis  of  the 
.sacrum — that  pus  had  invaded  the  right  sacro-iliac  synchondrosis  ;  there 
were  numerous  non-suppurating  infarcts  in  the  lungs,  and  in  the  left 
pleural  cavity  was  a  large  aniount  of  scro-purulent  exudation. 

Chronic  pysemia  is  characterized  clinically  by  a  ftdrlv  regular  liut 
excessive  diurnal  range  in  temperature,  continuing  for  weeks  or  months; 
few  or  no  striking  exacerbations  of  this  range  are  noted,  but  it  varies 
from  98°  F.  or  below  to  102°  or  over  almost  daily.  This  condition, 
which  has  been  described  as  hectic  or  irritable  fever,  is  associated  with 
slight  and  infrequent  chills,  with  great  loss  of  muscular  vigor,  emacia- 
tion, a  red  hut  not  necessarily  dry  tongue ;  there  is  constant  thirst. 
Usually  the  ajipetite  is  good,  lint  the  frerpient  attacks  of  diarrhoea  and 
the  emaciation  show  that  the  digestive  tract  does  not  assimilate  the  food 
taken  ;  the  ansemia  becomes  marked,  the  skin  jiale  and  even  slightly 


404  SEPTICEMIA,  PYEMIA,  AND  POISONED    WOUNDS. 

sallow  or  yellow.  The  intellect  is  clear,  the  sensibilities  acute,  but, 
owinw  to  the  extreme  weakness,  the  patient  remains  in  one  position, 
sunken  down  in  the  bed,  and  lied-sores  are  liable  to  form  :  tliese  appear 
especially  in  those  who  liave  diarrhiea,  owing  to  the  difficulty  in  keep- 
ing dry.  The  patient  sweats  botii  sleeping  aud  waking,  and  trembles  at 
the  slightest  exertion ;  even  the  effort  of"  speaking  exiiausts,  the  voice 
trembles,  and  he  weeps  readily.  Tiie  termination  comes  by  exhaustion 
from  the  diarrhoea,  or  an  exacerbation  of  the  attack  carries  iiim  off  in  a 
cou])lc  of  days. 

There  are  undoubted  cases  of  infective  fevers  in  which  the  symptoms 
are  sufficiently  marked  to  justify  the  opiuion  that  products  of  decom- 
position in  the  wound  and  infected  pus  may  be  present  at  the  same 
time,  producing  a  septic  pya'mia,  or  pyosepticannia  as  one  prefers  to  call 
it.  The  clinical  course  of  such  a  condition  is  characterized  by  prom- 
inent symptoms  of  both  diseases,  and  the  autopsy  reveals  the  presence 
of  metastatic  abscesses.  An  Italian  laborer  thirty-six  years  of  age,  who 
had  been  working  in  a  sewer,  was  admitted  to  the  New  Haven  Hospital 
on  July  10th  with  a  very  incomplete  history,  but  the  distinct  statement 
that  he  had  had  "  chills  and  fever"  for  two  M'eeks.  He  was  assigned  to 
the  medical  division  and  treated  for  malarial  fever.  On  admission  his 
temperature  was  103°  F.,  and  under  treatment  it  fell  to  99^°  in  the 
evening  of  the  second  day.  His  countenance  was  dusky,  and  he  M'as 
somnolent  most  of  the  time,  or  talking  in  his  sleep  and  breathing  irreg- 
ularly, sometimes  stertorously  :  his  temperature  rose  again,  however,  and 
for  the  next  three  days  it  was  irregularly  between  99°  and  101  j^°  F. 
He  had  several  loose  movements  of  his  bowels — Mas  occasionally  delir- 
ious, with  twitching  of  muscles  cf  face  and  tearing  at  the  bed-clothes. 
He  drank  plentifully  of  milk  ;  on  July  14th  a  large  abscess  was  found 
upon  his  right  thigh  and  another  on  his  right  forearm ;  these  were 
evacuated  and  found  to  contain  6  ounces  and  1  ounce  of  pus,  respec- 
tively. The  mental  condition  remained  about  the  same,  and  the 
temperature  arose  the  next  morning,  July  loth ;  after  opening  the 
abscesses  (which  were  washed  with  an  antiseptic  solution  and  drained) 
the  temperature  arose  to  101.8°  F.  The  temj^erature  for  the  next  thir- 
teen days  fluctuated  daily  from  about  99°  to  101  j^°  F.,  on  one  occasion 
going  up  to  103^°  F.  At  first  his  general  condition  improved  and 
his  appetite  was  good,  but  on  the  seventeenth  day  he  refused  liis  food, 
as  it  distressed  his  stomacii,  and  he  vomited  oecasionall}'.  He  got  over 
this,  and  his  general  symi)toms  were  more  satisfactory  again  in  that  he 
ate  and  slept  fairly  well,  with  occasional  lapses  of  his  bowels,  and  his 
mental  hebetude  disappeared.  On  July  28th  his  temperature  arose  to 
105°  F.,  falling  the  next  morning  to  99  jij-°,  and  on  the  30th  it  arose  to 
103j&5-°,  to  fiill  to  100.4°  ;  and  tliis  was  the  last  marked  fluctuation,  for 
the  fever  now  became  continuous,  ranging  for  the  next  three  days  just 
across  the  100°  F.  line,  then  for  a  couple  of  days  at  the  101°  F.  line; 
from  this  time,  August  6th  to  12th,  it  ranged  across  tlie  102°  line,  and 
on  the  evening  of  the  12th  it  arose  to  105y*„°  F.  During  this  time  his 
general  condition  failed  ;  he  became  weaker,  had  from  time  to  time  vom- 
iting and  diarrhoea,  with  appetite  in  the  intervals ;  there  was  no  change  in 
the  condition  of  the  abscesses  on  his  thigh  and  arm,  and  no  other  devel- 
opment externally.     On  August  8th  a  yellowish  color  appeared  on  the 


PYEMIA.  405 

skill ;  on  the  13tli  the  teraiieraturc  was  lower,  ami  continued  to  fall,  until, 
on  the  nioruing  of  the  14th,  it  was  at  Q9^jf°  F.,  as  low  as  it  had  been  for 
three  weeks.  He  died  the  following  day,  the  temperature  having  gone  up 
to  106y*^°  at  the  last.  The  course  of  the  disease  was  therefore  about  fifty 
days,  but  during  all  this  time  he  was  acutely  sick.  The  autopsy  showed 
the  liver  large,  fatty,  of  a  light  color  and  jjasty  consistence ;  the  spleen 
large,  soft,  and  pulpy,  with  embolic  infarctions.  In  the  wall  of  the  left 
ventricle  of  the  heart  (auriculo-vcntricular  valves)  there  was  an  abscess, 
the  size  of  a  walnut,  which  luul  opened  into  the  ventricle.  Both  kidneys 
were  enlarged,  the  left  the  most,  with  a  great  number  of  small  abscesses 
interspersed  through  it ;  the  right  liad  a  large  abscess  in  the  lower  por- 
tion, with  smaller  ones  in  numberless  quantity  throughout  the  whole 
organ.  Those  in  both  kidneys  were  undoubtedly  metastatic,  and  when 
one  appreciates  the  abscess  of  the  wall  of  tlie  heart  opening  into  the 
cavitv  of  the  left  ventricle,  pumping  pus  into  the  circulation  with  every 
pulsation,  the  source  of  the  countless  abscesses  of  the  kidneys  becomes 
evident.  How  long  it  had  been  doing  this  could  not  be  determined 
from  the  symptoms.  The  urine  was  repeatedly  examined,  but  beyond 
a  "trace"  of  albumin  showed  nothing  abnormal. 

The  treatment  of  pyaemia  resolves  itself,  like  that  of  other  septic 
infectious  processes,  into  local  and  constitutional,  and  the  local  into 
prophylactic  and  symptomatic  ;  and  of  the  latter  it  must  be  said  our 
means  of  relief  are  very  limite<l.  What  access  can  be  had  to  niultii)le 
metastatic  abscesses  of  the  lungs,  liver,  or  kidneys  ?  The  proplis'laxis 
of  pysemia,  however,  is  one  of  the  greatest  triumphs  of  modern  surgery, 
if  not  the  greatest.  When  Volkmann,  at  the  International  Congress 
of  1881  in  London,  stated  that  before  the  introduction  of  the  antiseptic 
treatment  of  wounds  the  mortality  in  hospitals  after  major  operations, 
from  septic  or  pviemic  conditions,  was  from  80  to  85  per  cent.,  and  that 
since,  if  a  case  was  lost  from  such  causes,  there  was  somewhere  a  surgical 
error,  he  said  nothing  that  has  not  been  abundantly  confirmed  by  the 
experience  of  the  surgeons  of  to-day.  Pyiemia,  which  twenty-five 
years  ago  was  the  horror  of  military  and  hospital  surgery,  is  now  un- 
known— nay,  impossible — as  the  result  of  operations  in  a  well-ordered 
hospital  or  of  a  properly-conducted  surgical  procedure,  and  instead  of 
hospitalism  being  the  reproach  of  surgery,  we  now  prefer  to  have  our 
operations  performed  in  hospitals,  feeling  more  confidence  that  we  can 
command  the  asepsis  there  than  in  other  places.  We  meet  pysemia 
occasionally,  it  is  true,  but  in  cases  that  we  do  not  have  control  of.  It 
is  as  preventible  as  any  other  infectious  disease.  Knowing  precisely  the 
nature  of  the  infectious  elements  and  what  will  destroy  them,  knowing 
exactly  from  what  point  they  gain  access  to  the  circulation,  and  in  most 
cases  having  control  over  this  process,  it  would  seem  that  the  surgeon's 
duty  is  fairly  easy  of  fulfilment.  The  fact  is,  as  above  stated,  that  in 
operations  where  the  wounds  are  frf)m  beginning  to  end  under  the  con- 
trol of  a  surgeon  who  appreciates  the  importance  of  asepsis  and  antisep- 
sis, the  disease  does  not  occur.  In  these  days  we  find  it  limited  entirely 
to  cases  that  do  not  come  under  proper  surgical  care  until  suppuration 
and  infection  are  established ;  to  cases  of  osteomyelitis  in  which  the 
diagnosis  is  not  made  early  or  the  proper  treatment  not  instituted  ;  fol- 
lowing cases  of  plilegmonous  erysipelas  with  extensive  subcutaneous  or 


40(3  SEPTICEMIA,   PYEMIA,  AXD  POISOyED    WOUXDS. 

subfascial  suppuration,  and  similar  conditions  of  septic  infection  which 
liave  ^\•itllstood  the  action  of  tlie  micro-organisms  of  decomposition, 
but  have  left  a  field  in  which  the  resistance  to  purulent  infection  is  of 
the  slightest. 

The  treatment  of  the  preliminary  conditions  leading  up  to  pysemia  con- 
sists of  the  most  rigid  antisepsis.  Frequent  dressings  for  the  removal 
of  pus,  washing  of  the  wounds  with  solutions  of  mercuric  l)ichloride  or 
other  of  tlie  antiseptic  or  disinfectant  remedies  that  have  been  referred 
to  under  the  treatment  of  septicemia,  laying  open  freeh'  pockets  or 
sinuses  of  pus,  making  the  position  of  the  part  such  as  to  allow  free  exit 
of  all  drainage, — are  matters  of  great  importance,  as  also  the  sterilization 
by  heat  or  otherwise  of  all  bandages  and  dressings,  and  the  most  thor- 
ough surgical  cleanliness,  especially  in  avoiding  any  possible  contact 
with  other  suppurating  wounds,  and  of  the  instruments  or  utensils  or 
other  apparatus  used  upon  them  without  intermediate  disinfection.  In 
some  hosjiitals  separate  wards  are  pi'ovided  for  the  suppurating  and 
non-suppurating  cases,  so  rigorous  is  the  warfare  against  c(intagi(m  :  iu 
Iviug-in  hospitals  it  is  the  rule  that  septic  cases  are  at  once  to  be  iso- 
lated. 

If  the  metastatic  abscesses  are  Avithin  reach,  they  are  to  be  treated  as 
abscesses  everywhere,  and  as  energetically  as  possible :  in  the  subcutane- 
ous or  subfascial  planes  they  slioukl  be  as  freely  opened  as  is  necessary  to 
obtain  and  maintain  complete  evacuation  of  the  pus,  and  then  be  disin- 
fected as  actively  as  possible.  Much  knowledge  may  be  gained  of  the 
formation  of  these  abscesses,  and  the  necessity  of  looking  for  them,  by 
carefully  watching  the  temperature.  In  a  case  presenting  distinct  pyemic 
features  following  a  phlegmonous  erysipelas  I  was  able,  by  judicious 
observation  on  the  part  of  the  nurse  as  to  chills  and  the  following  rise  in 
temperature,  to  diagnosticate  some  twenty  to  twenty-five  small  abscesses, 
one  after  the  other,  in  the  subcutaneous  tissue,  which  would  otherwise 
have  escaped  observation  until  they  had  ol>tained  a  large  size  or  had 
served  as  secondary  foci.  The  certainty  that  the  chill  was  the  evidence 
of  a  fresh  dejjosit  of  pus  was  the  incentive  to  more  careful  searching, 
and  in  almost  no  instance  were  we  deceived,  and  the  patient  recovered 
from  a  condition  that  seemed  at  times  hopeless.  Suppurating  joints  are 
to  be  freely  incised  and  carefully  washed  out ;  if  tiie  suppuration  has 
spread  into  the  neighboring  tissues,  amputation  is  to  be  considered,  and 
has  been  performed  with  the  result  of  saving  life  otherMise  doomed. 
Similar  advice  should  be  rendered  in  cases  of  pysemic  osteomyelitis, 
with  even  more  insistence  than  with  joints,  for  the  medulla  is  a  lymph- 
channel,  and,  being  hidden,  is  just  so  far  a  more  dangerous  situation 
from  wliicli  tlie  infected  i)us  may  be  spread.  It  is  a  matter  of  saving 
life  rather  than  of  conservative  surgery. 

When  throml)osis  occurs,  with  the  j)ossible  sequence  of  embolic  meta- 
stasis of  the  infected  clot,  the  proposition  has  been  made  to  in  some  way 
check  the  current  of  the  circulation  l^etween  the  thrombosis  and  the 
heart,  and  in  this  way  to  ])revent  the  wider  distribution  of  the  disease. 
Compression,  isolation,  and  ligation  of  the  vein  have  fmm  time  to  time 
been  em])loyed,  and  iu  some  cases  with  success.  These  are,  however, 
unusual  cases,  and  the  practice  has  not  become  general ;  the  fact  that 
all  thromboses  do  not  lead  to  emboli,  that  a  fairly  large  number  get 


POISONED    WOUNDS.  407 

■well,  makes  it  iueumbent  on  the  surgeon  to  hesitate  before  undertaking 
an  oiJeration  that  might  possibly  hasten  the  very  process  it  is  intended 
'to  check,  but  instead  to  try,  by  warm,  moist  antiseptic  applications,  sus- 
pension or  elevation  of  the  limb,  and  complete  rest,  to  obtain  regressi(m. 
Besides  the  local  treatment,  the  general  condition  of  the  patient 
demands  attention  :  the  indications  are  to  suj)port  the  patient  by  stinui- 
lants  and  tonics  and  to  nourish  by  food.  Milk-punch  and  egg-nog  made 
up  with  St.  Croix  rum  or  brandy  fulfil  the  therapeutic  indications.  Cin- 
chona is  also  frequently  of  benefit — whether  the  bark  or  its  alkaloid  is 
not  of  esjiecial  importance,  exce])t  for  the  smaller  dosage  of  the  latter. 
Too  much  stress  cannot  be  placed  on  the  absolute  necessity  of  an  abun- 
dance of  fresh  air  in  the  treatment  of  pyiemia  and  septicaemia. 

Poisoned  Wounds. 

In  poisoned  wounds  there  is  introduced  at  the  reception  of  the  injury 
some  substance  having  a  deleterious  influence  either  upon  the  tissues  at 
the  point  of  entrance  or  on  the  general  system,  or  on  both,  it  being  dis- 
tributed to  the  general  system  through  the  circulation,  the  deleterious 
result  being  out  of  all  proportion  to  the  injury  received. 

The  influence  is  .sometliing  more  than  that  of  a  foreign  body  wliich 
excites  local  action  in  attempts  to  get  rid  of  it,  and  if  prolonged  gives 
rise  to  fever.  It  is  difi'crcut  from  the  morbific  action  of  the  toxines  of 
septicemia  induced  by  micro-organisms  of  various  kinds.  It  is  differ- 
ent, again,  from  wounds  in  which  the  diseased  secretions  of  animals  are 
introduced  into  the  circulation,  giving  rise  to  the  phenomena  of  disease 
at  a  later  dav,  as  hydrophobia.  It  is  the  direct  action  of  the  substance 
itself  upon  the  tissues  (using  the  term  in  its  largest  sense)  with  which  it 
is  brought  in  contact,  and  the  ettect  j)roduced  depends,  in  a  given  case, 
entirely  upon  the  amount  introducetl  into  the  circulation. 

The  poisons  are  both  vegetable  and  animal  :  the  former  are  usually 
introduced  on  weapons  of  warf\irc  liy  the  natiA'es  of  the  islands  of  the 
Indian  Archipelago  and  of  South  America ;  the  latter,  by  certain  insects 
and  reptiles. 

In  the  East  Indian  islands  the  jioison  is  procured  from  incisions 
made  in  the  bark  of  the  upas  tree,  of  which  there  are  two  species,  the 
Upcw  aiitinr  and  the  Upaa  ticute,  the  poison  of  the  latter  being  the  more 
active  of  the  two.  Fabulous  tales  have  been  reported  of  the  effect  of 
poisonous  exhalations  from  these  trees;  these  are  now  known  to  be 
untrue.  There  exudes  from  the  incision  a  gum-resin,  which  is  poison- 
ous taken  internally  or  introduced  into  the  circulation.  The  arrow-  or 
lance-points  are  smeared  with  this  resin,  and  the  effects  of  the  poison  are 
great  prostration,  a  feeble  ir'.-egular  pulse,  vomiting,  involuntary  evacua- 
tions, convulsions,  and  death  from  cardiac  paralysis. 

I  am  unaware  of  any  direct  antidote  to  this  poison,  or  indeed  of  any 
investigations  looking  to  that  end,  but,  judging  from  the  symptoms  as 
detailed,  the  indications  are  for  active  stinmlation,  alcoholic  and  diffu- 
sible. 

Tlie  South  American  Indians  use  a  poison  variously  named  woorari, 
urari,  or  curare,  which  is  i)btained  from  various  species  of  Strychnos 
growing  in  the  Amazon  and  Omnoco  regions  and  in  British  Guiana. 


408  SEPTICEMIA,  PYEMIA,  AND  POISONED    WOUNDS. 

An  extract  is  made  from  the  bark  and  leaves,  and  in  tliis  tlie  points  of 
the  arrows  arc  dipped.  It  is  very  powerful ;  a  small  quantity  introduced 
into  the  circulation  acts  by  paralyzini>;  the  motor  nerves,  shown  first  in  a 
feeling  of  weariness  and  disinclination  to  move,  followed  rajiidly  by 
complete  paralysis  of  all  muscles,  inciudinjjj  those  of  respiration,  by  which 
death  comes,  the  heart  acting  after  the  respiration  has  ceased.  In  larger 
doses  the  vagus  nerve  and  heart  become  paralj'zed.  The  action  is  quite 
rajiid,  death  occurring  in  a  few  minutes  Avith  fatal  dosage.  If  the  amount 
introduced  be  not  sufticicnt  to  kill  at  once,  life  may  be  saved  by  keeping 
up  artificial  respiration  until  the  j)oison  be  eliminated  by  the  kidneys, 
which  occurs  fairly  raiiidly. 

There  is  no  evidence  that  the  North  American  Indians  have  ever  used 
poisoned  arrows  as  such.  The  traditions  to  that  end  are  based  on  certain 
rites  with  which  they  intersperse  their  war-dances  preparatory  to  a  foray. 
They  mix  up  a  lot  of  stuff  in  which  jnitrcfying  animal  matter  obtained 
from  snakes  and  other  reptiles  enters  largely  ;  in  this  they  dip  the  pciints 
of  their  arrows,  using  various  incantations  of  a  semi-religious  kind,  in 
order  that  the  arrows  may  be  more  potent  against  their  enemies.  This 
mess  of  course  contains  a  great  number  of  microbes  of  decomposition, 
which,  entering  the  tissues  at  the  wound,  may  produce  scpticaMuia,  and 
be  so  far  poisonous ;  beyond  this  there  is  nothing. 

Animal  poisons  are  introduced  either  as  stings  or  as  bites.  Stings  are 
usually  made  by  insects  carrying  the  A\'capon  at  the  posterior  extremity 
of  the  body,  the  venom  being  secreted  by  a  gland,  and  emptied  into  the 
wound  at  the  time  of  puncture  by  the  sting,  which  is  usually  barbed  or 
serrated  along  its  edges.  The  sting  is  really  an  ovipositor,  consequently 
only  females  sting.  Exceptions  to  this  are  found  in  certain  gnats  and 
bugs,  of  which  the  common  mosquito  and  bed-bug  are  familiar  examples: 
these  sting  by  a  proboscis,  and  both  sexes  are  venomous,  as  is  also  the 
case  with  biting  insects,  of  which  the  spider  is  the  most  common. 

The  venomous  sting-carrying  insects  Avith  which  the  physician  has 
principally  to  do  are  wasps,  hornets,  bees,  and  some  species  of  scorpions. 
This  by  no  means  exhausts  the  list  of  poisonous  insects,  and  there  are 
some  venomous  flies,  but  they  are  rare.  Care  must  be  taken,  however, 
to  difierentiate  between  venomous  flies  and  those  which  serve  simply  as 
carriers  of  infective  material.  There  are  no  known  scavengers  compar- 
able to  the  common  house-fly  :  frequenting  and  living  upon  decomposing 
animal  matter,  it  may,  and  frequently  does,  carry  the  microbes  of  putre- 
faction and  of  infection  to  minute  wounds,  and  thereby  excite  a  septic 
process  which  kills. 

The  action  of  the  venom  upon  the  human  subject  is  similar  in  all.  A 
local  irritation  of  varying  intensity  is  excited,  depending  upon  the  amount 
of  poison  injected.  If  there  be  enough  of  it,  constitutional  symptoms 
are  excited,  but  there  are  great  differences  in  individuals  as  to  the  amount 
required  to  produce  such  effects.  It  is  also  well  established  that  persons 
may  become  in  time  immune  to  the  actit)n  of  the  poison  ])y  repeated  stings  : 
this  is  the  experience  of  most  people  living  contimiously  in  mosquito- 
infested  localities,  and  with  those  who  work  among  bees  the  effect  l)e- 
comes  less  and  less  with  successive  doses  of  the  poison,  so  that  finally  in 
each  case  the  sting  excites  no  more  action  than  the  simple  jiunctui-e. 

Usually  the  sting  produces  much  more   pain  than  can  be  ascribed 


POISOXED    WOUyDS.  40ft 

to  the  puncture  alone,  lasting  some  hours.  In  a  very  short  time,  a 
few  minutes,  after  the  puncture  an  area  of  redness  surrounds  the  point, 
which  also  rapidly  becomes  oedematous :  with  the  appearance  of  the 
cedema  the  centre  becomes  white,  and  there  is  then  a  swollen,  red  areola 
with  a  white  spot  in  the  centre,  which  itches  and  burns.  It  is  evident  that 
the  action  of  the  poison  is  first  to  produce  a  paralysis  of  the  vasomotor 
nerves,  allowing  the  dilatation  of  the  blood-vessels  for  a  considerable 
area  around  the  puncture,  but  whether  the  white  spot  in  the  centre  be 
due  to  a  cutting  off  of  the  circulation  by  the  swelling  around  it  (Van 
Buren),  or  to  a  constriction  of  the  vessels  themselves  l)y  the  action  of  the 
poison  emptying  them  of  blood,  may  be  a  question  ;  but,  taking  into  con- 
sideration the  fact  that  in  severe  cases  there  is  a  slough  at  the  centre,  I 
am  disposed  to  regard  the  white  centre  as  the  innncdiate  effect  of  the 
poison.  Not  infrecpiently  tiie  sting  itself  is  broken  off  and  remains  in 
the  wound  :  this  occurs  if,  as  is  usually  the  case,  the  insect  is  knocked 
away  at  the  moment  of  stinging ;  if,  however,  it  be  not  disturbed,  the 
weapon  is  withdrawn  entire.  Where  the  sting  remains  there  is  the  ad- 
ditional irritation  consequent  to  the  presence  of  the  foreign  body.  Not 
infrequently  there  is  vesication  over  the  reddened  area,  and  in  a  consid- 
erable number  of  cases  the  redness  and  swelling  and  irritation  extend 
perhaps  over  the  whole  extremity,  with  considerable  pain  lasting  for 
several  days,  even  weeks,  and  a  feeling  of  numbness  with  autesthcsia  and 
stiffness  in  movement,  showing  that  the  nerve-trunks  are  affected  in  both 
their  sensory  and  motor  filaments.  Usually  a  sting  or  two  or  three  do 
not  produce  an  effect  upon  the  general  system,  but  if  there  be  a  large 
number  the  constitutional  effect  may  be  great.  Death  has  followed  in  a 
few  minutes  after  tlie  attack  of  a  swarm  of  bees  wliicli  had  been  disturbed. 
The  symptoms  are  referable  to  the  heart  and  lungs :  the  pulse  is  feeble 
and  irregular,  the  respiration  hurried,  superficial,  and  gasping,  the 
countenance  livid,  the  skin  clammy ;  there  are  great  prostration  and 
veritable  collapse,  in  which  condition  the  patient  dies.  Additional 
danger  exists  when  the  stings  are  in  the  vicinity  of  the  air-passages 
from  the  swelling  interfering  with  the  respiration,  death  having  taken 
place  from  a?dema  of  the  glottis  producing  suffocation.  Wounds  in 
the  mouth  occur  sometimes  in  eating  fresh  honey  in  the  comb  or  in 
eating  fresh  fruit  picked  up  from  the  ground  with  the  insects  upon  it. 

The  treatment  of  the  local  irritation,  after  removing  the  sting, 
consists  in  cold  applications,  with  amnioniacal  water  if  agreeable.  The 
indications  for  general  treatment  depend  a  little  on  how  the  heart  is 
acting :  if  that  be  fairly  strong,  anodynes  may  be  given  to  allay  the 
pain  and  irritation,  but  if  it  l)e  feeble,  both  alcoholic  and  diffusible 
stimulants  must  be  used  ;  besides  the  usual  forms  of  alcohol  or  brandy, 
whiskey,  etc.,  the  preparations  of  amnuniia,  carbonate  or  muriate,  and 
camphor,  may  be  exhibited,  together  with  hypodermic  injections  of 
digitalis,  nitro-glyceriu,  and  strychnia. 

Many  varieties  of  spiders  arc  venomous,  the  tarantula  being  perhaps 
the  most  so,  but  scorpions,  galeodes,  centipedes,  are  all  more  or  less 
dangerous.  The  effect  of  their  bites  is  in  the  main  similar  to  that  of 
stings,  as  just  described,  but  they  are  apt  to  be  more  severe,  leaving  their 
effects  upon  the  nerve-trunks  much  longer.  These  animals  are  usually 
shy  and  keep  themselves  hidden  until  disturbed,  and  then  rush  out  from 


410  SEPTICEMIA,  PYMMIA,  AND  POISONED    WOUNDS. 

inipxpec'tcd  places,  retreatinsj;  ao;ain  to  tlicir  hiding-places.  The  taran- 
tula, luiwever,  iiiiist  be  reoartlcd  as  an  exception,  as  it  is  liable  to  be  quite 
piiirnacioiis,  attacking  animals  much  larger  than  itself"  most  vigorously. 
The  hiding-places  are  oftentimes  quite  unexpected,  as  appears  from 
an  account  in  the  Australian  Ilediml  Gazette  for  June,  1894,  in  Mhieh 
three  cases  of  s])ider-l)ites  upon  the  penis  are  detailed,  the  nesting-jdace 
of  the  animal  being  under  the  seat  of  an  out-of-doors  privy  closet.  All 
the  cases  occurred  in  the  month  of  Marcli,  and  in  each  case  the  exami- 
nation of  the  locality  revealed  a  brood  of  spiders  of  the  genus  Lathro- 
dectus,  consisting  of  a  mother  with  from  twenty  to  thirty  young  ones ; 
and  Dr.  Parry,  who  reports  the  cases,  suggests  that  they  are  venomous 
only  during  the  breeding  season  :  it  is  jirobable  that  they  are  simply 
more  easily  excited  to  attack  at  this  time,  owing  to  the  maternal 
instinct.  In  these  cases,  besides  the  usual  local  effects  of  a  burning 
pain  and  swelling,  the  remote  effects  on  the  nervous  system  were 
.shown  l)y  the  occurrence  in  the  course  of  a  couple  of  hours  after  the 
injury  of  an  exceedingly  disagreeable  pain,  as  of  pins  pricking  him,  in 
the  patient's  toes  :  this  gradually  spread  up  to  his  ankles  and  knees;  the 
part  became  bathed  in  a  cold  perspiration.  The  temperature  Avas 
.sligjitly  sulinormal  and  tiie  heart's  action  feeble.  The  pain  continned 
for  forty-eigiit  hours,  and  the  perspiration,  conhned  at  first  to  the  lower 
extremities,  became  general,  and  so  profuse  as  to  soak  through  the 
blankets  on  the  bed.  It  gave  off  a  peculiar,  very  offensive  cadaverous 
odor.  The  patient  was  exceedingly  restless,  unable  to  sleep  without 
anodynes,  and  suffered  pain  all  the  time.  He  was  confined  to  his  room 
for  five  days,  but  for  two  weeks  there  were  darting  jiains  through  his 
legs  and  around  the  lower  part  of  his  abdomen.  Dr.  Parry  regards  the 
lesion  as  that  of  a  peripheral  neuritis. 

Of  poisonous  serpents  there  are  four  genera  in  this  country — viz.  of 
the  rattlesnake  there  are  two,  the  Crotahis,  with  fourteen  distinct  species, 
and  the  C'«(/(//.so(i«,  with  four;  the  copperheads  and  moccasins  are  of 
one  genus,  the  Aricistrodon,  divided  into  four  species;  the  vijjers 
Ektps  are  of  five  species. 

The  first  three  genera  above  mentioned  have  movable  poison-fangs 
situated  in  the  njijier  jaw,  which  ordinarily,  and  always  when  the  mouth 
is  closed,  lie  folded  back  and  are  concealed  Ijehind  the  upper  li])s,  Imt 
which  on  opening  the  mouth  widely  are  capable  of  becoming  erect.  The 
viper  has  small  permanently-erect  poison-fangs,  situated  fai-ther  back  in 
the  jaw  than  in  the  Crotalidfe. 

In  Europe  the  viper,  Pelias  berus,  is  the  only  venomous  serpent  met 
with,  and,  as  comjiared  with  those  of  America  and  India,  it  is  ahuost 
harmless ;  deaths  from  viper-bites  are  extremely  rare  in  Europe. 

It  is  in  India,  however,  that  the  venomous  snakes  are  met  with  in  the 
greatest  number,  variety,  and  virulence,  the  mortality  from  snake-bites 
being  very  great.  According  to  Sir  Josej)h  Fayrer,  the  deaths  fr(  im  snake- 
bites alone  are  about  1  :  10,000  of  all  deaths.  The  iirincipal  genera  are  the 
cobra  Naja,  or  hooded  snake,  the  krait  Bungarux,  the  ophiophagus, 
and  the  daboia.  The  first  named  is  the  most  venomous  known  and  is 
the  most  frequently  met  with  :  nearly  one-fourth  of  the  deaths  from 
serpent-bites  are  caused  by  the  cobra.  Next  in  frequency  are  the  kraits  ; 
then  ojjhiophagus,  a  large  and  very  ferocious  snake,  having  the  habit  of 


fe 


POISONED    WOUNDS.  411 

devoui'ing  other  snakes,  lience  the  name ;  the  daboia  is  of  tlie  viper 
genus  and  most  venomous  of  its  race.  There  are  many  other  genera, 
but  thcv  are  rehitively  unimportant,  except  as  showing  the  great  numbers 
in  that  country.  The  true  Hydrophidea  (water-snalies  or  sea-serpents) 
are  found  principally  in  the  neighborhood  of  the  islands  of  the  Indian 
and  Pacific  Oceans  and  of  the  seas  between  China  and  Australia.  They 
are  exceedingly  venomous  and  somewhat  aggressive,  but  not  large, 
usually  less  than  five  feet  in  length. 

The  mechanism  of  the  poison  apparatus  is  essentially  the  same  in  all. 
The  venom-gland,  analogous  to  the  ])aroti(l,  i*  situated  upon  the  superior 
maxilla  below  and  behind  the  eye ;  it  is  a  flattened  oval  in  shape,  taper- 
ing forward  to  a  duct  leading  to  the  base  of  the  fang  in  front.  There 
is  no  especial  sac  or  reservoir  for  the  collection  of  the  venom,  but  as  the 
duct  runs  through  the  centre  of  the  gland  it  dilates  a  trifle,  and  in  this 
there  is  a  small  store  of  venom  collected.  The  fang  itself  is  not,  as  is 
commonlv  supposed,  movable  at  its  attachment  to  the  jaw,  but  that  por- 
tion of  the  maxilla  witii  the  fang  inserted  in  its  socket  is  attached  loosely 
to  the  rest  of  the  bone,  and  on  dilating  the  mouth  widely  this  portion 
of  the  jaw  turns  in  such  a  way  as  to  bring  the  point  of  the  fang  to 
project  downward  and  a  little  backward  ;  with  the  closure  of  the  jaws, 
the  fangs  being  erect,  they  are  driven  into  the  skin  if  it  lie  an  animal : 
tlic  temporal  muscles  press  upon  the  gland  and  squeeze  the  poison  out 
into  the  duct  and  along  the  groove  in  the  posterior  edge  of  the  fang,  and 
it  is  thus  led  to  and  injected  into  the  tissues  of  the  animal  attacked. 
The  fang  itself  is  very  sharp,  sickle-shajicd,  with  the  concavity  back- 
\\ard.  The  erection  of  the  fang  is  a  voluntary  act  in  itself,  not  the 
effect  simply  of  opening  the  jaws  widely  ;  the  mechanism  is  quite  com- 
])lex,  but  it  is  luinecessary  to  describe  it  here.  In  feeding  the  fangs  are 
not  erected,  but  are  kept  folded  l^ack  and  covered  by  a  sheath  of  mucous 
membrane.  The  poison  is  ejected  with  considerable  force,  sufficient 
when  it  misses  its  mark  to  throw  it  five  or  six  feet  away. 

In  the  vipers  the  fangs  are  permanently  fixed,  and  are  situated  farther 
back  in  the  jaw  than  in  the  serjients  aljove  described  ;  they  are  not  so 
long  or  curved,  and  the  groove  is  not  so  deep.  The  gland  is  not  so 
large,  either ;  the  jaws  eann(jt  be  opened  so  widely,  and  the  muscles 
do  n(3t  act  with  so  much  force.  Taking  it  altogether,  it  is  a  much  less 
effective  mechanism,  and  in  consequence  vipers  are  not  nearly  as 
])oisonous. 

The  effect  of  the  injection  of  the  venom  is  a  "  swelling  at  that  point, 
with  intense  violet-black  discoloration  of  the  skin,  whieli  gradually 
extends  over  an  area  of  several  scpiare  inciies.  The  tissues  in  the 
immediate  neighborhood  are  soaketl  with  extravasated  blood.  If  death 
occurs  soon,  local  ex'ti'avasation  may  be  all  that  is  visible,  but  if  it  be  post- 
poned for  a  short  time,  then  smaller  extravasations  are  found  in  distant 
tissues.  Most  frequent  and  most  ])r()uounccd  are  subpleural,  subperito- 
neal, and  subpericardial  ecchymoses,  l)ut  tlie  whole  organism  is  deeply 
affected,  the  tissues  being  congested  and  presenting  a  much  darker  apjiear- 
ance  than  normal.  The  blood  does  not  seem  to  coagulate  readily  within 
cavities  or  interstices  of  the  body  unless  death  follows  almost  instan- 
taneously. In  cases  which  live  longer  the  blood  remains  constantly  in 
a    li(iuid   state   or   coagulates   imperfectly,   and    then    only   after   being 


412  SEPTICEMIA,  PY/TIMIA,  AND  POISONED    WOUNDS. 

exposed  to  the  air,  resembling  in  tliis  particular  the  state  of  that  fluid 
observed  in  conditions  of  asphyxia." ' 

The  symptomatology  is  similar  for  the  different  genera,  the  diiferences 
being  due  to  the  amount  of  venom  injected  and  individual  susceptibility. 
Besides  the  points  just  given,  the  whole  limb  swells,  ecchymoscs  a])pear 
under  the  skin  and  s:uiious  vesicles  upon  the  surface,  and  if  the  patient 
lives  the  skin  directly  about  the  wound  becomes  gangrenous.  The  con- 
stitutional symptoms  are  of  great  severity  and  rapidity  :  the  pulse  is 
feeble  and  fluttering ;  at  first  nausea  and  looseness  of  the  bowels  may 
occur,  followed  by  involuntary  evacuations  of  urine  and  faeces ;  there 
is  great  difficulty  in  breathing,  with  pain  about  the  prsecordia ;  at  first 
there  are  great  anxiety  and  restlessness,  but  as  the  effect  of  the  poison 
extends  to  the  nervous  system  the  sufferer  becomes  delirious,  then  indif- 
ferent, then  somnolent,  and  dies  in  a  state  of  coma.  The  time  of  death 
varies  from  a  few  minutes  to  several  hours  after  the  bite. 

In  non-fatal  cases  there  is  considerable  variety  in  the  symptoms,  and 
cases  are  reported  of  singular  delay  in  their  appearance.  Thus,  Dr. 
Yarrow^  states  that  constitutional  symptoms  were  not  present  until  four 
days  had  passed,  the  local  symptoms  also  being  sim])ly  troublesome; 
but  with  the  coming  on  of  the  constitutional  symptoms  the  local  became 
more  active,  simulating  phlegmonous  erysipelas.  The  ])atient  continued 
to  grow  worse  for  twelve  days,  when  under  treatment  the  disease  took  a 
favorable  turn,  and  he  eventually,  in  the  course  of  about  four  months, 
recovered.  In  other  cases,  again,  there  arc  recurrent  symptoms,  coming 
on  after  intervals  of  varying  length  ;  nor  are  the  symptoms  themselves 
constant.  Dr.  Piifard  of  New  York  reports  a  case  where  a  vesicular 
eruption  appeared  at  varying  intervals  of  from  three  months  to  a  year 
in  a  young  woman  whom  he  first  saw  six  j^ears  after  the  bite.  Dr.  Cole- 
man reports  a  scaly  eruption  resembling  ichthyosis  coming  on  in  two 
successive  years  after  a  venomous  snake-bite  (variety  not  given),  and 
Dr.  Yarrow's  case  had  marked  constitutional  symptoms  at  about  the 
anniversary  of  the  bite,  Avith  a  good  deal  of  local  reaction  :  he  reports 
two  other  cases  having  similar  experiences.  The  evidence  of  these 
recurrences  comes  from  too  reliable  observers  to  be  ignored.  It  is  diffi- 
cult to  explain  them,  but  that  they  have  to  do  with  a  neurosis  is  quite 
evident. 

The  evidence  that  the  Hdodcrma  Ruspedum  (the  "Gila  monster"),  a 
lizard  found  in  Northern  Mexico  and  the  South-western  United  States, 
is  poisonous  is  too  conflicting  to  allow  a  positive  expression  of  opinion, 
the  latest  experiments  by  Dr.  Yarrow  being  altogether  negative,  though 
most  careful  observers  have  thought  it  is  poisonous,  the  grooved  fling 
indicating  poisonous  qualities. 

The  treatment  of  venomous  snake-bites,  to  be  efficacious,  requires 
to  be  of  the  most  energetic  character.  The  first  aim  is  to  prevent  the 
poison  from  getting  into  the  general  circulation,  or  to  have  it  enter  in 
such  small  quantity  and  so  slowly  that  it  shall  not  act  powerfully  on  the 
nervous  system — that  its  action  be  delayed.  Therefore  tie  a  ligature  as 
tightly  above  the  bitten  part  as  jjossible  to   be  borne  :  the   larger  tlie 

^  Mitchell  and  Eeichert :  "  Researches  on  the  Venom  of  the  Rattlesnake,"  Smithsonian 
Contributions  to  Knowledge,  No.  647,  p.  139. 

^  Amer.  Jour,  of  Med..  Sciences,  April,  1884,  p.  422. 


POISONED   WOUNDS.  413 

limb — /.  e.  the  nearer  the  body — the  more  difficulty  there  will  be  in 
doing  this.  Then  the  part  may  be  suckeil  (with  sound  lij).s),  but,  better 
yet,  let  it  be  excised  freely  and  deeply,  the  sucking  applied  afterward, 
and  bleeding  facilitated.  I  can  see  no  good  to  be  accomplished  by  cau- 
terizing :  the  wound  is  too  small  to  be  followed  into  its  recesses  by  any 
caustic  liquid  or  solid,  and  nothing  is  gained  by  cauterizing  the  skin 
over  and  around  it.  The  ligature  should  be  kept  on  if  the  patient  can 
bear  it,  even  after  constitutional  symptoms  have  become  severe,  as  it 
must  delay  the  rapidity  of  the  entrance  of  the  poison  into  the  general 
circulation.  The  indications  for  constitutional  treatment  arc  active  dif- 
fusible and  alcoholic  stimulants.  Aromatic  spirits  of  ammonia,  whis- 
key, brandy,  camphor,  etc.  are  in  order,  but  the  overwhelming  of  tlie 
system  with  whiskey  or  alcohol,  in  obedience  to  the  ])opular  fallacy  that 
to  get  a  man  drunk  will  cure  him,  has  undoubtedly  cost  many  lives  from 
the  whiskey.  Patients  are  usually  greatly  excited,  and  tlicrcfore  can 
tolerate  large  quantities  of  stimidants  \\ithout  intoxication,  but  if  a  man 
be  intoxicated  he  is  in  a  less  favorable  condition  to  eliminate  the  poison. 
So  long  as  the  heart's  action  is  feeble  and  the  pulse  intermittent,  stimu- 
lants and  digitalis  and  strychnine,  Avith  perhaps  nitro-glycerin,  may  be 
given  freely. 

The  cautious  statement  of  Drs.  Mitchell  and  Reichcrt  that  "  potassic 
permanganate,  ferric  chloride  in  the  form  of  the  liquor  or  tincture,  and 
tincture  of  iodine  seem  to  be  the  most  active  and  promising  of  the  gen- 
erally available  local  antidotes,"  is  sufficient  answer  to  the  vaunted 
claims  of  all  sorts  of  nostrums  as  antidotes. 

Death  comes,  according  to  the  observations  of  these  most  capable 
oliservers,  "  through  paralysis  of  the  respiratory  centres,  paralysis  of  the 
heart,  hemorrhages  in  the  medulla,  or  possibly  through  the  inability  of 
the  profoundly  altered  red  corpuscles  to  perform  their  functions.  There 
can  be  no  question,  however,  that  the  respiratory  centres  are  the  j)arts  of 
the  system  most  vulnei-able  to  venom,  and  that  death  is  commonly  due  to 
their  paralysis."  '  "  The  outlook,  then,  for  an  antidote  for  venom  which 
may  be  available  after  the  absorption  of  the  poison  lies  clearly  in  the 
direction  of  a  physiological  antagonist,  or,  in  other  words,  of  a  substance 
which  will  oppose  the  action  of  the  venom  on  the  most  vulnerable  parts 
of  the  system.  The  activities  of  the  venoms  are,  however,  manifested  in 
such  divers  ways,  and  so  profoundly  and  rapidly,  that  it  does  not  seem 
probable  that  we  shall  ever  discover  an  agent  which  shall  be  capable  at 
the  same  time  of  acting  efficiently  in  counteracting  all  the  terrible  ener- 
gies of  these  poisons." " 

'  Amer,  Jour,  of  Med.  Sciences,  April,  18S4,  p.  156.  ^  Ibid.,  p.  157. 


TRAUMATIC  FEVER,  ERYSIPELAS,  AND 

TETANUS. 

By  J.  COLLINS  WARKEN,  M.  D. 


I.  Traumatic  Fever. 

The  constitutional  disturbance  which  occurs  during  the  healing  of  a 
wound  is  known  as  traumatic  fever. 

Traumatic  fever  may  be  divided  into  two  principal  varieties — primary 
wound-fever  and  secondary  wound-fever. 

Primary  wound-fever  may  be  also  subdivided  into  two  varieties — 
aseptic  fever  and  septic  or  surgical  fever. 

Aseptic  fever  is  a  febrile  disturbance  which  occurs  in  woiuid-healing 
by  first  intention.  In  this  form  of  healing  the  syuiptoms  of  local  iuflam- 
mation  are  absent,  and  it  was  supposed  in  the  early  days  of  antiseptic 
surgery  that  sucli  wounds  would  not  be  accompanied  by  fever.  It  w^as 
found,  however,  that  the  fever-ciu've  often  rose  to  a  considerable  height. 
In  tins  respect  the  conditions  differ  from  those  seen  in  surgical  fever, 
where  the  constitutional  disturbance  keeps  pace  with  the  varying  con- 
ditions of  the  inflammation  in  the  wound. 

The  cause  of  tliis  rise  of  temperature  was  at  first  not  fully  under- 
stood, but  experiments  on  anunals  have  shown  that  the  absorption  of 
fibrin-fermeut  is  often  accompanied  by  serious  symptoms.  Fibrin  is 
formed  l)y  the  union  of  two  filirin-generators,  fibi'inogen  and  para- 
glolmlin,  with  the  co-operatiou  of  fibrin-ferment.  Fibrinogen  is  fotnid 
in  the  blood-plasma,  wliile  the  fibrin-ferment  and  the  paragloliulin  are 
for  the  most  part  found  in  the  white  blood-corpuscles.  If  the  fibrin- 
ferment  is  introduced  experimentally  into  the  circulation,  extensive 
coagulation  of  the  blood  will  be  the  result,  and  the  death  of  the  animal 
speedily  eusues. 

During  the  process  of  healing  by  first  intention  a  certain  amount  of 
fibi-in-ferment  is  absorbed  from  tlic  extravasated  blood,  and  also  otiier 
substances  which  are  found  in  the  exudation  which  accompanies  the 
inflammatory  process. 

In  a  large  wound  healing  l)y  first  intention  we  find  not  only  extrav- 
asated blood  and  exuded  serum,  but  minute  fragments  of  tissue  wliich 
have  been  separated  from  the  surface  of  the  wound  during  the  opera- 
tion, and  are  subsequently  disintegrated  and  absorbed.  These  materials 
when  absorbed  exert  a  pyrogenic  action  upon  the  system.  Their 
close  relationship  to  living  substances,  however,  renders  them  but 
slightly  injurious,  and  they  produce  in  consequence  only  a  mild  type 
of  fever. 

415 


416  TRAUMATIC  FEVER,  ERYSIPELAS,  AND   TETANUS 

Tho  symptoms  of  aseptic  fever  arc  few  in  nunibcr.  The  patient 
experiences  no  sense  of  discomfort,  such  as  is  observed  in  other  forms 
of  fever.  The  skin  is  not  so  hot  or  dry,  tiie  urine  is  not  diminislied, 
and  there  is  far  less  loss  of  weight  tiian  in  septic  fever.  The  thermom- 
eter, however,  shows  that  there  is  a  I'isc  of  temperature  of  from  one  to 
tliree  degrees,  and  tiicre  is  also  a  corresponding  increase  in  the  pulse-rate, 
which  continues  so  long  as  any  absorption  is  taking  place  from  the  inte- 
rior of  the  wound.  The  patient  is,  however,  unconscious  of  fever,  and 
is  often  able  to  move  aliout  the  room  witiiout  discomfort.  This  form  of 
fever  lasts  usually  from  one  to  five  days,  or  may  continue  longer  when 
hemorrlingc  has  taken  place  and  a  considerable  amount  uf  blood  has  to 
be  absorbed.  Fever  of  tiiis  type  is  seen  in  cases  of  simple  fracture  and 
in  large  wounds  healing  by  first  intention,  in  cases  of  luematoma,  and 
in  contused  wounds  where  there  has  been  considerable  iicmorrhage. 

Sejitie  or  surf/icd/  fever  is  observed  in  wounds  liealing  witii  more 
or  less  septic  inlliunmation,  such  as  are  seen  following  accidents  or  in 
cases  M'here  the  j)rinciples  of  antiseptic  surgery  have  not  been  observed. 
In  such  cases,  although  the  wound  may  unite  in  the  larger  part  of  its 
extent,  there  is  a  great  amount  of  redness  and  swelling  and  the  other 
symptoms  of  local  inflammation.  A  considerable  discharge  will  take 
place  from  any  ojien  jioint  in  the  wound,  and  perhajis  also  from  the 
openings  around  the  stitches,  and  in  a  few  days  a  more  or  less  extensive 
supjjuration  may  take  place,  although  in  fortunate  cases  a  great  portion 
of  the  wound  may  be  healed  before  the  formation  of  pus  has  taken 
place.  These  active  changes  in  the  wound  were  formerly  supposed  to 
be  symptoms  of  the  brisk  reaction  in  the  wound,  and  were  thought 
essential  to  the  pi'ocess  of  repair.  We  now  know  that  they  are  due  to 
sepsis.  The  constitutional  symptoms  are  corresjjondingly  severe  in  these 
cases,  and  keep  pace  pretty  accurately  with  the  amount  of  inflammation 
which  occurs  in  the  wound. 

As  an  ordinary  result  of  an  operation  or  accident  there  is  a  certain 
amount  of  shock,  the  temperature  falls  below  the  normal,  the  skin 
is  cold  and  clammy,  and  the  pulse  weak.  The  following  day  reaction 
occurs  :  the  pulse  and  tcmperatiu-e  rise,  the  skin  becomes  hot  and  dry, 
the  tongue  coated,  and  the  patient  suffers  from  considerable  thirst  and 
restlessness.  On  the  evening  of  the  second  day  the  tempei'ature  is  still 
higher  ;  there  is  great  discomfort,  and  the  patient  may  also  suffer  from 
pain  owing  to  the  swelling  of  the  wound.  On  this  account  sleep  is  dif- 
ficult ;  the  patient  may  not  only  suffer  from  insomnia,  but  nervous 
symptoms  will  be  present,  and  in  severe  cases  often  dclirimu.  The  tem- 
perature drops  slightly  c\-cry  morning,  to  rise  still  higlier  in  the  evening. 
With  the  subsidence  of  the  local  inflammation  the  temperature  also  falls, 
and  with  the  discharge  of  pus  from  the  wound  the  fall  may  be  quite  rapid, 
and  there  will  be  at  the  same  time  relief  to  all  the  other  symptoms  of 
inflanunation. 

Traumatic  fever  usually  lasts  about  a  week,  at  which  time,  if  no 
extensive  suppuration  has  occurred,  the  temperature  will  be  found  to 
have  reached  the   normal  line. 

The  cause  of  this  form  of  fever  is  found  to  be  the  presence  of  bac- 
teria in  the  retained  secretions  of  the  wound.  A  limited  number  of 
micro-organisms  find  their  way  into  tlie  circulation  from  this  source. 


TRAUMATIC  FEVER.  417 

The  decomposition  which  they  have  set  up  in  the  retained  fluid  liberates 
a  certain  number  of  cliemieal  substances  which  are  also  absorbed.  The 
ptomaines  and  toxiucs  thus  introcUiced  into  the  circulation  exert  a  pyro- 
genetic  action.  It  is  probable  that  no  one  form  of  virus  habitually 
causes  traumatic  fever,  but  that  various  substances  have  this  effect.  For- 
tunately, they  do  not  exert  a  very  poisonous  action  upon  the  tissues,  but 
sutficient  to  cause  considerable  fever  and  discomfort  io  the  patient.  AVith 
the  advent  of  suppuration  these  substances  and  organisms  are  carried 
away  in  the  discharge  from  the  wound,  and,  as  those  wliicli  have  already 
obtained  an  entrance  into  the  circulation  are  speedily  eliminated,  the 
fever  then  disappears. 

Sccniid/irt/  trdioid-fcrfr,  or  suppurative  fever,  occurs  when  pus  has 
formed  which  has  not  an  opjxn'tunity  to  escape  from  the  wound,  and  in 
consequence  chemical  substances  formed  in  the  pus  by  the  bacteria  are 
absorbed  into  the  system.  In  this  case  the  fever-curve,  instead  of  falling 
to  the  normal  line  at  the  end  of  the  first  week  of  the  healing  process, 
rises  again,  and  this  rise  in  some  cases  may  be  accompanied  by  a  chill. 
There  is  usually  a  marked  morning  remission,  with  a  subsccpient  rise  of 
temperature  every  evening,  which  becomes  more  exaggerated  as  the  sup- 
purative process  extends.  Marked  types  of  this  form  of  fever  are  seen 
in  the  su})purati()n  which  follows  compound  fractures  and  in  operative 
wounds  in  which  the  flow  of  pus  has  been  obstructed.  The  pus  conse- 
quently burrows  in  the  surrounding  connective  tissue.  In  these  cases 
the  symptoms  which  accom|)any  the  rise  of  temperature  are  similar  to 
those  which  we  have  just  desi'ribed.  The  patient  suffers  from  dryness 
of  the  skin  and  coated  tongue,  headache,  malaise,  and  in  severe  cases  a 
mild  delirium.  When  a  free  evacuation  of  the  pus  has  been  obtained  the 
symptoms  disappear  and  the  temperature  falls  to  the  normal  line.  In 
unfavorable  cases,  where  the  jius  has  burrowed  in  various  directions, 
chronic  suppuration  is  established,  and  the  fever  now  resumes  the  cha- 
racteristic remittent  type.  In  the  morning  the  tem])erature  is  normal  or 
even  subnormal,  but  in  the  evening  there  is  a  sharp  rise,  varying  from 
one  to  six  degrees.  Unless  the  progress  of  the  suppuration  is  checked 
there  is  a  marked  change  in  the  appearance  of  the  patient.  .The  loss  of 
flesh  is  often  very  great,  prostration  occurs  with  the  evening  rise  of  tem- 
perature, the  characteristic  hectic  flush  is  established,  and  with  the  tall 
during  tlic  night  there  is  the  jirofuse  perspiration  or  night-sweat  which 
is  so  characteristic  of  this  condition.  Diarrluea  may  also  set  in  to  aggra- 
vate the  patient's  condition.  In  fatal  cases  emaciation  becomes  extreme, 
the  joints  are  unusually  prominent,  and  bed-sores  appear.  The  patient 
finally  becomes  exhausted  and  succumbs  to  the  disease. 

Tlie  })rincipal  change  found  at  the  post-mortem  examination  is 
amyloid  degeneration,  which  occurs  in  the  spleen,  liver,  intestines,  and 
kidneys.  This  is  supposed  to  be  caused  by  the  constant  presence  of 
alkaline  salts  produced  by  suppuration.  This  type  of  fever  has  been 
sometimes  confounded  with  pyiemia,  and  is  called  by  some  authors 
pyajmia  simplex,  in  contrast  with  the  multiple  or  metastatic  form  of 
pyiemia.     It  should  not,  however,  be  confounded  with  this  affection. 

Treatment. — Aseptic  fever  usually  requires  little  or  no  interference 
on  the  part  of  the  surgeon.  Persistence  in  the  rise  of  temperature  indi- 
cates the  presence  of  an  unusual  amount  of  blood  collected  beneath  the 

Vol.  I.— 27 


418  TRAUMATIC  FEVER,  ERYSIPELAS,  AND  TETANUS. 

lips  of  the  wouikI.  In  such  cases  tlio  hciding  ]>rocess  maybe  hastened  by 
the  introduction  of  the  probe  or  of  a  temporary  drain  to  allow  the  escape 
of  the  blood-serum,  whieli  prevents  tlie  accurate  coajitation  of  the  surfaces 
of  tiie  wound.  In  surgical  fever  a  careful  watcii  nnist  l)e  kept  as  to  tiie 
condition  of  the  wound,  in  order  that,  if  su|)puration  is  established,  pro- 
vision may  be  made  ibr  the  proper  evacuation  of  jnis.  The  removal  of 
one  or  more  stitches  or  the  introduction  of  the  drainage-tube  may  be 
sufficient  for  this  purpose.  If,  liowever,  tiie  general  appearance  of  the 
wound  is  threatening,  it  should  be  freely  opened,  a  thorough  disinfec- 
tion of  its  surfaces  siiould  lie  effected,  and  provision  made  for  the  free 
discharge  of  tiie  products  of  dccomj)osition. 

When  it  is  clear  that  su]ipurative  fever  is  cstablislied,  the  pus  which 
is  causing  this  disturliance  should  be  followed  relentlessly  in  all  direc- 
tions. In  localized  collections  of  pus  a  moderate  opening  is  often  suf- 
ficient to  check  the  furtiier  progress  of 'sujipuration,  but  wlicn  pus  begins 
to  ijurrow  free  incision  shoukl  be  made  and  the  walls  of  tiie  wound 
should  be  curetted,  so  as  to  remove,  if  possible,  all  jiyogenic  organisms. 
When  it  is  impossible  to  lay  open  the  wound  in  its  entire  extent,  a 
connter-opening  should  be  made  at  some  prominent  point,  througii  which 
drainage-tubes  leading  in  various  directions  may  be  introduced.  The 
wound  should  lie  thoroughly  flusiied  with  some  antisejitic  agent  suf- 
ficiently weak  to  avoid  poisoning  by  absorption.  For  this  purpose  car- 
bolic acid  in  tiie  strengtii  of  1  :  200  may  be  nsed,  or  corrosive  sublimate 
in  a  solution  of  the  strength  of  1  :  5000.  The  penetrating  power  of  the 
corrosive  is  not  so  great  in  this  case  as  that  of  carbolic  acid,  as  the  latter 
is  able  to  incorporate  itself  more  completely  with  greasy  substances. 
Sulpho-naphthol,  in  a  strength  of  1  :  260,  or  creolin  may  be  used.  Tiie 
disinfection  of  suppurating  wounds  may  also  be  eft'ectually  accomplished 
by  the  application  of'peroxide  of  liydrogen. 

The  drainage  may  consist  of  rubber  tubing  or  of  strands  of  iodoform 
or  sterilized  gauze. 

The  strength  of  the  patient  should  be  carefully  watched.  Alcoholic 
stimulation  is  of  great  importance  in  these  cases.  The  patient  will  often 
be  able  to  bear  a  large  amount  of  alcohol  witliout  discomfort.  Good 
hygienic  surroundings  should  be  secured,  and  tlie  patient  may  often  be 
placed  in  the  open  air  for  many  honrs  at  a  time,  even  in  cold  weather, 
with  benefit  during  the  process  of  chronic  suppuration. 

n.  Erysipelas. 

Erysipelas  is  an  acute  inflammation  of  tiie  skin  spreading  along  its 
upper  layers  and  occasionally  penetrating  to  the  deeper  tissues.  It  may 
involve  mucous  membranes.  It  is  accompanied  by  fever.  It  lias  a  tend- 
ency to  more  or  less  complete  recovery,  but  it  may  recur.  The  name  is 
derived  from  ipu3p6c,  red,  and  vtirAa,  skin. 

Although  the  disease  was  known  to  the  ancients,  reliable  reports 
previous  to  the  epidemic  described  in  France  in  1750  are  rare.  Epi- 
demics are  described  as  occurring  in  Great  Britain  in  1777  and  1780,  and 
also  in  1821  and  1832.  A  very  extensive  epidemic  of  erysipelas  occurred 
in  this  country  in  1842,  and  the  disease  is  described  as  prevailing  in  vari- 
ous parts  of  Europe  in  the  following  year.     The  accounts  of  this  last 


ERYSIPELAS.  419 

epidemic  are  clear,  and  show  the  disease  to  have  existed  in  a  far  more 
malignant  type  than  that  seen  to-day.  In  fact,  epidemics  of  this  disease 
are  at  the  present  time  practically  unknown  in  civilized  communities. 
The  disease  often  assumed  at  that  time  the  phlegmonous  type,  and 
worked  its  way  deeply  between  the  muscles  of  the  trunk,  and  some- 
times involved  a  whole  extremity.  In  New  England  it  spread  from 
village  to   village  and  many  lives  were  sacrificed. 

The  streptococcus  of  erysipelas  was  first  described  by  Fehlciscn.' 
The  cocci  grow  in  serpentine  chains.  They  are  small,  varying  from  0.3  fi 
to  0.4  p  in  diameter  ;  they  are,  however,  somewhat  larger  than  the  strepto- 
coccus pyogenes.  The  culture  of  the  coccus  upon  gelatin  develops  slowly, 
and  appears  as  a  very  delicate  grayish-white  film,  not  unlike  that  of  the 
streptococcus. 

The  question  of  the  identity  of  these  organisms  is  still  a  mooted  one, 
although  the  feeling  at  present  tends  to  the  belief  that  the  streptococcus  of 
erysipelas  is  a  specific  organism.  It  has  been  suggested  by  some  observers 
that  in  the  suppurati\'e  forms  of  erysipelas  pus  is  developed  by  the  action 
of  the  pyogenic  cocci ;  others  believe  that  the  streptococcus  of  erysipelas 
when  developing  in  the  subcutaneous  tissue  has  a  more  virulent  local 
action  and  may  become  pyogenic. 

The  cocci  are  found  in  the  capillary  h'mphatics  of  the  skin  chiefly, 
but  are  also  occasionally  seen  in  the  capillary  blood-vessels  and  small 
veins.  The  growtli  of  tiic  organism  is  most  active  near  the  red  margin 
of  the  er^'sipclatous  l)lush.  The  virus  may  lie  transmitted  to  different 
parts  of  the  body  through  the  circulation,  and  the  constitutional  dis- 
tui'bance  is  probabh'  due  to  the  presence  of  the  cocci  or  their  ptomaines 
in  the  circulating  blood.  The  virus  gains  entrance  to  the  body  almost 
invariably  through  a  wound  :  even  in  the  so-called  cases  of  idiopathic 
erysipelas  the  cocci  find  their  way  through  some  minute  abrasion  in 
the  skin. 

The  clinical  evidence  of  the  contagiousness  of  erysipelas  is  abundant. 
Stille^  reports  the  following  striking  example:  In  1852  a  man  arrived 
in  Platte  county,  INIissouri,  suffering  from  erysipelas  of  the  face.  He 
was  nursed  by  a  farmer,  who  himself  fell  ill  of  the  disease.  A  second 
farmer,  who  assisted  in  nursing  these  two  patients,  was  seized  by  the 
disease,  and  subsequently  six  other  persons,  who  helped  to  nurse  in  their 
turn,  were  attacked.     No  other  case  occurred  in  the  neighborhood. 

The  occurrence  of  erysipelas  following  vaccination  was  so  frequent 
in  Boston  in  the  winter  and  spring  of  1850  that  vaccination  was 
temporarily  abandoned.  The  disease  was  probably  not  conveyed  in 
the  vaccine  virus,  but  by  an  unclean  instrument. 

The  close  relationship  of  ervsi]ielas  and  j)uerperal  fever  has  been 
recognized  by  many  authorities,  and  the  impropriety  of  attending  a 
case  of  confinement  after  handling  erysipelas  is  now  well  understood. 
Trousseau  describes  an  epidemic  of  puerperal  fever  which  rendered  the 
closing  of  a  hospital  necessary.  In  the  hospitals  to  which  pregnant 
women  were  transferred  er^-sipclas  liroke  out  among  the  surgical  cases 
in  many  instances. 

Exposure  to  cold  was  for  a  long  time  supposed  to  be  a  cause  of  ery- 

'  Die  Etiologk  des  Erysipels,  Berlin,  1883. 

''  International  Encyehpctdiu  of  Surgery,  vol.  i.  p.  165. 


420  TRAUMATIC  FEVER,   ERYSIPELAS,  AND   TETANUS 

sipclas,  but  it  acts  uudoubtedly  us  u  predisposing  cause  only,  i-cndering 
the  patient  debilitated  and  therefore  more  susceptible  to  the  disease.  The 
spring  and  late  winter  months  are  regarded  by  many  surgeons  as  a  par- 
ticularly favorable  season  for  the  development  of  the  disease. 

Erysipelas  is  comparatively  rare  in  childhood,  although  it  is  seen  in 
badly-arranged  lying-in  hospitals  as  erysipelas  iwoiiatornm  when  puer- 
peral fever  prevails.  It  does  not  occur  so  often  in  old  age  as  in  the 
prime  of  life. 

Certain  constitutional  conditions,  as  alcoholism  and  diabetes,  are 
supposed  to  act  as  predisposing  causes,  and  some  individuals  frequently 
attacked  by  erysipelas  are  supposed  to  have  a  predisposition  to  the 
disease. 

Symptoms. — The  disease  usually  manifests  itself  at  first  by  a  chill, 
with  fever  and  symptoms  of  gastric  disturbances.  The  tongue  is  coated, 
and  there  is  often  a  sense  of  oppression  at  the  epigastrium,  and  some 
enlargement  of  the  lymphatic  glands  belonging  to  the  vessels  leading 
from  the  jwint  of  infection.  An  examination  of  the  wound  does  not, 
however,  show  any  origin,  as  yet,  of  an  infective  inflammation.  Occa- 
sionally the  constitutional  disturbance  is  so  slight  as  to  pass  unnoticed, 
and  the  first  sign  of  any  disorder  is  in  the  Mound  itself.  In  twenty-four 
to  forty-eight  hours  from  the  time  of  the  beginning  of  the  attack  there 
is  an  itchmg  or  inirning  sensation  in  the  vicinity  of  the  wound  and  the 
skin  becomes  tender  to  the  touch.  There  is  at  first  a  blush  on  the  skin 
in  the  vicinity  of  the  wound,  ^diich  gradually  deepens  in  tint  and  has  a 
more  dusky  hue  than  the  rose  color  t)f  hj^pertemia.  There  is  a  yellowish 
tinge  mingled  with  the  red,  and  this  becomes  more  evident  upon  pres- 
sure, which  shows  a  yellow  stain  to  the  diseased  part  during  the  moment 
in  which  the  blood  is  pressed  aside.  The  swollen  tissues  become  tense 
and  hard  and  do  not  pit  on  pressure.  The  swelling  is  most  evident 
about  the  eyelids,  where  the  skin  lies  loose,  and  also  about  the  genitals. 
As  the  swelling  and  infiltration  of  the  part  increase,  small  vesicles  form 
which  may  at  times  attain  considerable  size. 

When  the  local  inflanmiation  is  fully  developed  it  shows  a  tendency 
to  spread,  and  the  outline  of  the  diseased  part  is  usually  well  marked 
and  is  often  quite  irregular.  The  inflammation  runs  its  course  at  any 
one  particular  point  in  three  or  four  days,  but  in  the  mean  time  it  has 
invaded  new  regions,  and  this  process  may  go  on  for  a  considerable 
period  of  time,  and  the  surfaces  involved  in  the  inflammation  are  often 
quite  extensive  {erysipelas  mic/raris).  It  may  even  revisit  jtarts  which 
have  already  been  infected  and  are  convalescent  from  the  original  attack. 
The  tendency  to  recur  is  a  marked  feature  of  the  disease,  but  so  also  is 
the  tendency  to  recovery,  and  it  is  rare  that  the  attack  lasts  longer  than 
two  weeks.  As  the  inflammation  subsides  there  is  an  abundant  desqua- 
mation, and,  as  in  the  superficial  form  of  erysipelas  there  is  no  sup- 
puration, there  is  a  complete  return  to  the  normal  condition  of  the  skin. 

The  condition  of  the  wound  during  an  attack  of  erysijielas  varies 
greatly.  In  the  early  stages  of  the  healing  process  a  wound  the  edges 
of  which  are  in  apposition  may  reopen,  the  interior  presenting  a  slough- 
ing aspect,  and  in  the  severer  forms  extensive  destruction  of  tissue  may 
take  place,  which  may  involve  vessels  of  considerable  size,  producing 
secondary  hemorrhage.     At  other  times,  particularly  when  the  disease 


ERYSIPELAS.  421 

has  attacked  a  wound  in  tlie  stage  of  granulation,  there  appears  to  be 
little  local  disturbance,  and  the  healing  process  may  go  on  even  more 
rapidly  tlian  l)ef<»rc. 

The  constitutional  symptoms  correspond  pretty  closely  with  the 
amount  of  local  inflammation  in  the  majority  of  cases.  Accompanying 
the  gastric  disturbance  there  are  usually  a  chill  and  a  rapid  rise  of  tem- 
perature, follo\vcd  liy  a  slight  fall  on  the  following  morning.  The  sub- 
sequent changes  of  temperature  are  most  erratic,  corresponding  to  the 
amoiuit  of  inflammation — as  a  rule,  however,  showing  the  remittent 

The  tongue  is  heavily  coated,  and  there  may  be  vomiting  and  diar- 
rlicea.  In  the  most  severe  cases  there  may  be  delirium,  and  the  disease 
shows  a  tendency  to  assume  a  tyjihoid  type. 

The  variety  of  erj'sipelas  known  as  facial  cnji^ipelas  is  often  called 
idiopathic,  as  it  does  not  appear  to  take  its  origin  from  a  wound.  The 
virus  in  these  cases  probably  obtains  an  entrance  through  some  small 
wound,  abrasion,  or  pustule  in  the  skin.  The  disease  is  first  observed 
on  the  nose  or  near  one  of  the  lachrymal  ducts,  and  spreads  slowly  along 
the  lines  of  the  cheek  beneath  the  orbit  in  the  direction  of  the  ear.  As 
it  approaches  the  temple  it  may  rise  to  tlie  forehead  and  invade  the 
scalp,  or  it  may  turn  downward  to  invade  tlie  neck.  The  chin  is  rarely 
involved.  In  mild  forms  the  disease  gradually  fades  away  as  it  reaches 
the  ear,  and  the  amount  of  constitutional  disturbance  is  in  such  cases 
very  slight.  In  the  severer  types  of  facial  erysipelas  the  amount  of 
swelling  is  usually  very  great ;  the  eyelids  become  oedematous,  and  the 
eyes  are  closed,  the  disiigurenient  becoming  at  times  so  great  that  the 
patient  is  unrecognizable.  The  color  of  the  skin  is  scarlet,  and  tlie  sur- 
face is  covered  with  vesicles  wliich  here  and  there  run  together,  forming 
bullffi  of  considerable  size.  Tlie  lymphatic  glands  in  front  of  and  behind 
the  ears  are  enlarged,  and  when  the  scalp  is  invaded  the  glands  in  the 
back  of  the  neck  are  involved.  In  the  severer  forms  of  facial  erysipe- 
las, particularly  if  the  scalp  be  involved,  there  is  delirium,  and  a  slight 
tendency  to  tlelirium  is  noticed  even  in  mild  forms  of  the  disease.  This 
appears  to  be  caused  either  by  reflex  nerve-irritation,  or  by  a  vasomotor 
disturbance  causing  hypersemia  of  the  meninges,  or  by  an  extension  of 
the  septic  processes  through  the  orbit  to  the  membranes  of  the  brain. 
Fortunately,  the  latter  complication  is  of  rare  occurrence,  and  with  the 
sul;)sidence  of  the  inflammation  of  the  skin  the  cerebral  symptoms 
usually  disappear. 

The  tendency  of  the  inflannnation  to  involve  the  deeper  tissues  of 
the  orbit  is  characteristic  of  the  graver  forms  of  erysipelas,  and  blind- 
ness is  sometimes  caused  by  the  extension  of  the  septic  process  to  the 
eye  itself,  jiroducing  either  a  panophthalmitis  or  degenerati\'c  changes  in 
the  optic  nerve.  A  rare  complication  is  the  formation  of  an  orbital 
abscess. 

The  duration  of  facial  erysipelas,  like  that  of  other  forms,  is  cpiite 
variable.  In  mild  cases  the  disease  rarely  lasts  beyond  one  week ;  in 
the  severer  types,  or  in  cachectic  individuals,  the  inflannnation  may  last 
several  weeks  before  it  entirely  disa])pears. 

Phleojioxous  Erysipelas. — When  the  disease  spreads  to  the 
deeper  tissues  the  virus  appears  to  assume  greater  activity.    The  amount 


422  TRAUMATIC  FliVER,  ERYSIPELAS,  AND   TETANUS. 

of  swelling  is  in  sucli  cases  much  greater,  and  tlie  skin  1)eeomes  tense 
and  hard.  Vesicles  form,  wliieh  are  sometimes  filled  with  bloody  fluid, 
and  the  surrounding  parts  are  swollen  and  (edematous.  The  eonstitu- 
tioual  disturbance  is  great.  Chills  frequently  occur,  and  the  fever 
assumes  a  typhoid  character.  As  pus  forms  in  the  subcutaneous 
tissue,  the  skin  above  loses  its  tension,  and  becomes  boggy  and  more  or 
less  movable  on  the  parts  below.  A  free  incision  gives  vent  to  a 
sanious  ])us,  mingled  with  shreds  of  sloughing  tissue  which  have  been 
likened  to  masses  of  wet  blotting-paper.  The  suppurative  process  gen- 
erally extends  for  some  distance  beneath  the  surface,  and  several  incis- 
ions are  usually  necessary  to  drain  the  parts  properly.  The  muscles 
may  be  separated  from  one  another,  and  even  joints  may  be  involved  in 
the  septic  process. 

In  some  cases  gangrene  of  the  skin  may  occur,  and  on  such  occasions 
the  skin  Ijecomes  a  dusky-red  in  color  and  large  bnlhe  form  filled  with 
bloody  serum.  It  is  principally  in  old  and  feeble  iiulividuals  that  such 
a  complication  occurs.  It  is  known  as  gangrenous  erysipelas.  The  con- 
stitutional disturbance  is  in  such  cases  very  great,  and  many  patients  will 
succumb  with  symptoms  of  pysemia  or  of  septictemia. 

EEYSIPELA.S  Neonatorum  is  most  freciuently  seen  in  hospital  prac- 
tice. It  takes  its  origin  from  the  granulating  surface  of  the  stump  of 
the  umbilical  cord.  The  slight  blush  about  the  navel  is  at  first  accom- 
panied by  but  little  fever.  As  the  disease  progresses  the  septic  process 
may  extend  over  the  abdomen  and  involve  the  genitals  and  thighs. 
There  is  then  high  fever,  and  the  child  cries  and  is  restless.  In  the 
later  stages  collapse  supervenes,  and  the  child  dies  on  from  the  sixth  to 
the  tenth  day  of  the  disease.  Gangrene  is  an  occasional  complication 
of  this  form  of  erysipelas.  The  disease  may  spread  along  the  hypogas- 
tric arteries  or  the  umbilical  vein,  and  peritonitis  may  occasionally  occur 
in  consequence. 

Erysipelas  of  Mucous  Membranes  occasionally  occurs.  When 
the  pharynx  is  involved  the  color  of  the  throat  is  a  dark  red,  and 
there  is  a  tendency  to  dyspnoea  and  difliculty  in  deglutition.  There 
is  also  a  marked  enlargement  of  the  cervical  glands.  The  thorax  may 
become  the  seat  of  diphtheritic  inflammation,  and  suppuration  may  take 
place  in  the  submucous  tissues.  The  mouth  may  also  be  involved  in 
the  inflammatory  process,  and  the  tongue  then  becomes  greatly  swollen 
and  congested,  giving  rise  to  that  variety  of  disease  known  as  "  black 
tongue." 

The  disease  is  said  to  extend  along  the  air-passages  to  the  lungs,  giv- 
ing rise,  perhaps,  to  oedema  of  the  glottis  or  to  septic  pneumonia  or  jmeu- 
monia  migrans.  Such  forms  of  erysipelas  arc  extremely  rare  at  the 
present  time,  and  were  observed  principally  in  those  malignant  epidemics 
which  have  already  been  mentioned. 

Erysipelas  may  occasionally  extend  from  the  vulva  to  the  vagina  and 
from  the  nates  into  the  rectum. 

Pathological  Anatomy. — An  examination  of  the  principal  seat  of 
the  disease — the  skin — shows  that  there  is  a  considerable  exudation 
in  the  rete  mucosum  and  in  the  upper  layers.  The  superficial  net- 
work of  lymphatics  is  filled  with  streptococci,  which  are  most  numerous 
near  the  margin  of  the  inflammation.     There  is  a  considerable  hyper- 


ERYSIPELAS.  423 

jemia  of  the  blood-vessels  of  the  affected  part,  and  the  surrounding 
tissues  are  infiltrated  with  leucocytes.  In  some  types  of  erysipelas 
minute  abscesses,  which  during  life  have  escaped  observation,  are  often 
found  in  the  cutis. 

The  changes  observed  in  the  circulating  blood  are  supposed  to  be  due 
to  the  micrococci,  although  they  are  rarely  found  there  in  large  numbers. 
The  red  corpuscles  are  found  to  assume  a  erenated  appearance,  and  dis- 
solve and  run  togetiier  readily.  The  white  corijuscles  are  usually  in- 
creased in  number.  Endcjcarditis  is  occasionally  observed.  Tiie  gastric 
symptoms  appear  to  be  due  to  the  condition  of  the  system,  rather  tiian 
to  any  local  change.  Catarriial  ulcers  are,  however,  sometimes  found  in 
the  small  intestines.  The  brain  and  membranes  are  hyperjemic  and 
cedematous  in  tiie  severe  forms  of  facial  erysipelas.  Suppurative  men- 
ingitis is,  however,  extremely  rare.  Enlargement  of  the  spleen  is  often 
found,  and  there  is  frequently  some  cloudy  swelling  in  the  kidneys. 
Tlie  }>arotid  gland  may  also  become  inflamed. 

The  curafire  influence  of  erysipelas  (erysipele  salutaire)  has  long  been 
recognized.  Wounds  iieal  more  rapidly,  cin-onic  inflammations  of  the 
skin  disappear,  and  old  ulcers  begin  to  granulate.  Tilmans  reports 
several  eases  of  sarcoma  of  the  face  and  neck  which  either  disappeared 
after  an  attack  of  erysijielas  or  were  greatly  reduced  in  size.'  In  one 
case  the  patient  died  of  the  erysi})elas,  and  the  cells  of  the  tumor  were 
found  to  have  undergone  extensive  fatty  degeneration.  Fehleisen,  in 
order  to  demonstrate  the  specific  character  of  tiie  streptococcus  of  ery- 
sipelas, inoculated  man  on  several  occ^asions  witii  success,  the  human 
inoculations  being  used  also  for  tiie  purpose  of  testing  the  curative  clia- 
racter  of  tiie  virus.  A  death  luu'ing  occurred  in  the  hands  of  uuitators 
of  tills  method,  the  experiments  were  abandoned. 

Recently,  Coley  ^  has  experimented  with  the  virus,  and  has  collected 
38  cases  of  malignant  disease  in  wliicli  erysipelas  had  occurred  either  by 
accident  or  intent.  There  were  17  cases  of  carcinoma,  of  which  3  were 
permanently  cured,  and  of  17  cases  of  sarcoma  7  were  well  and  free 
from  recurrence  from  one  to  seven  years  after  the  attack  of  erysipelas. 
As  in  some  cases  when  the  pure  culture  has  been  used  death  has  followed 
the  inoculation  in  the  hands  of  other  surgeons,  Coley  has  substituted  the 
toxic  ]iroduets  of  tiie  erysijielas  coccus  for  tiie  pure  culture.  Tiiey  are 
thus  obtained  :  The  strejitococeus  is  planted  in  bouillon  culture  and 
allowed  to  grow  for  six  weeks,  wlieii  tlie  bouillon  is  filtered.  The  fil- 
tered material  contains  no  bacteria,  but  is  rich  in  toxic  products. 

Spronck's  method  of  preparation  is  as  follows:*  The  streptococcus 
is  planted  in  two  large  flasks  of  equal  size  nearly  filled  with  bouillon. 
Tile  cotton  plugs  are  covered  witli  a  layer  of  paraffin.  The  flasks  are 
sul)jccted  to  a  temperature  of  from  33°  to  35°  C.  for  fifteen  days.  After 
the  purity  of  the  culture  has  lieen  verified,  the  contents  of  one  of  the 
flasks,  to  which  5  per  cent,  glycerin  lias  been  added,  is  subjected  for 
three  hours  to  a  current  of  steam  at  100°  C,  and  is  finally  reduced  to 
one-tenth  its  volume  by  boiling.  After  cooling  this  liquid  is  added  to 
the  contents  of  the  other  flask  and  the  mixture  is  filtered. 

'  Deutsche  Ch!riir<i!p,  Lieferung  5,  1880. 

"  American  JiniriKil  Medical  Sciences,  May,  1893. 

'  Annates  de  I'Insliiul  Pasteur,  No.  10,  1892. 


424  TRAUMATIC  FEVER,  ERYSIPELAS,  AND   TETANUS. 

The  diagnosis  of  erysipelas  is  not  easy  to  establish  definitely  in  the 
early  stages.  The  chill,  tlie  gastric  syniptoins,  and  the  enlargement  of  the 
lymphatic  glands  are  indications  which  should  canse  the  surgeon  to  exam- 
ine the  wound  carefully  for  signs  of  the  disease.  It  is  not  until  the 
blush  appears  that  a  certain  diagnosis  can  be  made.  The  doughy  swell- 
ing with  tenderness  of  the  skin  and  tlie  irregular  raised  margin  of  the 
infianied  area  serve  to  distinguish  it  from  erythema,  which  may  originate 
in  some  local  irritation  or  infiannnatory  process.  There  may  at  times  be 
difficulty  in  deciding  between  phlegmonous  erysipelas  and  diffuse  suppu- 
ration of  the  cellular  tissue.  This  latter  complication  arises  usually 
from  a  wound,  and  from  the  l)eginning  the  signs  of  a  deep-seated  sup- 
purative inflannnation  are  manifest,  whereas  in  erysipelas  tlie  inflamma- 
tion liegins  upon  the  surface,  and  the  superficial  changes  are  then  not  a 
marked  feature. 

The  prognosis  of  erysipelas  is,  as  a  rule,  fiivorable.  There  is  a  tend- 
ency on  the  part  of  the  disease  to  self-linxitation,  and  the  disease  does 
not  remain  in  any  one  spot  more  than  four  or  five  days.  If  erysip- 
elas attacks  a  wound  during  the  early  stages  of  the  healing  process,  it  is 
more  likely  to  be  severe  than  during  the  granulation  stage.  It  varies  also 
with  the  age  of  the  patient.  In  very  young  infants  it  is  a  most  serious 
condition,  and  in  the  aged  it  is  with  difficulty  that  the  disease  is  thrown 
off,  ])articularly  in  tlie  traumatic  form  of  erysipelas.  In  facial  erysipelas, 
which  attacks  old  people  so  frequently,  the  disease  is  often  very  mild  in 
its  course. 

The  severity  of  the  disease  may  be  said  to  vary  according  to  the 
resisting  j^ower  of  the  patient.  The  tendency  to  relapse  should  always 
be  borne  in  mind. 

Although  the  disease  may  not  lie  severe  in  its  type,  it  may  pro- 
duce fatal  complications,  such  as  secondary  hemorrhage.  The  sight 
may  be  lost  in  facial  erysipelas,  and  spasm  of  the  glottis  may  occur 
if  there  is  great  swelling  in  the  neck  during  an  attack.  The  effect  of 
antiseptic  surgery  seems,  however,  to  render  the  attacks,  as  a  rule, 
milder. 

Treatment. — The  treatment  of  erysipelas  may  be  both  local  and  con- 
stitutional. In  general,  it  may  be  said  that  the  treatment  should  be 
supjiorting  and  that  depletion  should  be  avoided.  The  diet  should  be 
carefully  adapted  to  the  disturbed  digestive  functions,  but  should  be 
nutritious.  Alcoholic  stimulants  may  be  used  freely  in  the  asthenic 
cases,  but  care  should  be  taken  as  to  over-stimulation  M'liere  there  are 
symptoms  of  cerebral  hyperaemia. 

The  use  of  iron  has  been  strongly  recommended  in  P]ngland.  Bell 
recommended  25  drops  of  the  tincture  of  tlie  cliloride  of  iron  every  two 
hours,  day  and  night.  Iron  is  supposed  to  exert  a  favorable  action  upon 
the  red  blood-corpuscles  and  to  have  a  constringing  effect  upon  the  blood- 
vessels. Quinine  may  be  combined  with  it,  but  these  remedies  are  not 
so  much  used  since  more  dependence  has  been  placed  upon  the  local 
treatment.  Camjihor,  digitalis,  and  aconite  have  also  been  recommended 
for  this  disease. 

Antipyretics  exert  but  little  influence  upon  the  fever,  and  are  to  be 
avoided,  owing  to  their  depressing  influence  upon  the  heart's  action. 
Delirium  may  be  relieved  by  the  use  of  the  bromides  or  chloral,  and 


ERYSIPELAS.  425 

opium  in  some  form  may  be  needed  to  ensure  relief  from  jwin  and  to 
give  repose. 

Among  local  remedies,  iodine  enjo_yed  for  a  long  time  a  great  rcputa^ 
tion,  as  it  was  supposed  to  prevent  the  sj^read  of  the  local  inilammation. 
It  has  now  been  replaced  by  antiseptics.  The  effect  of  antiseptic  drugs, 
applied  to  the  snriace  of  the  skin,  upon  the  bacteria  in  the  capillary 
Ivmphatics  is  not  as  great  as  might  be  supposed.  Although  the  skin 
absorbs  certain  drugs  freely,  particularly  those  containing  carljolic  acid, 
it  is  probable  that  the  organisms  are  restrained  in  their  activity  to  a  cer- 
tain degree  only,  and  are  rarely  destroyed  by  this  agent. 

Carbolic  acid  may  be  applied  to  the  part  in  an  ointment  in  the  strength 
of  1  : 1  ( )0,  oi-  it  may  1  )e  used  in  an  antiseptic  poultice  which  has  been  dipped 
in  a  solution  of  1  :  200.  James  C.  White  recommends  a  lotion  containing 
1  drachm  of  carbolic  acid  to  4  ounces  each  of  alcohol  and  water.  This 
should  be  applied  upon  a  cloth,  and,  as  it  evaporates  quickly,  should  fre- 
quently be  renewed.  It  is  M'ell  adapted  to  facial  erysipelas  and  to  parts 
that  can  conveniently  be  exjiosed. 

Carbolic  acid  can  theoretically  be  brought  more  intimately  in  contact 
with  the  bacteria  by  subcutaneous  injections.  These  should  be  made 
along  the  margin  of  tlie  diseased  area.  The  dilhculty  of  introducing  a 
sufficiently  large  quantity  of  the  solution  at  the  most  needed  points  is  an 
obstacle  to  the  success  of  this  method.  It  should  always  be  remembered 
that  carbolic  poisoning  may  result  from  a  too  free  use  of  the  drug,  and 
the  urine  should  be  watched  for  the  characteristic  olive-colored  staining 
\vhile  this  treatment  is  employed. 

Creolin  and  phenyl  are  preparations  which  are  good  substitutes  for 
carbolic  acid  in  antiseptic  poultices.  Phenyl  (sulpho-naphthol)  may  be 
used  in  a  strength  of  1  :  250.  Ichthyol  may  be  applied  when  it  is  desired 
to  avoid  strong  antiseptic  dressings.  Mild  zinc  ointment  and  ])lain  vaseline 
are  comfortable  applications.  Tiie  frequent  application  of  licpiid  vaseline 
to  the  face,  or  a  solution  of  carbolic  acid  in  oil  1  :  100,  with  a  camel's-hair 
brush,  is  a  mode  of  treating  facial  erysipelas  which  is  both  comfortable 
and  effective.  If  it  is  desired  to  retain  a  dressing  ujion  the  face,  this 
may  be  done  by  means  of  strips  of  gutta-percha  tissue,  which  is  light  and 
easily  holds  oily  sul^stances  in  contact  with  the  skin. 

When  the  infective  process  goes  on  to  suppuration,  as  in  phlegmonous 
erysipelas,  drainage  nuist  be  obtained  by  free  incisions  as  the  surest  means 
of  arresting  the  spread  of  the  disease.  The  knife  should  penetrate  as  far 
as  the  subcutaneous  cellular  tissue,  as  it  is  at  this  point  that  pus  will  be 
found.  The  sloughing  tissue  should  be  removed  as  thoroughly  as  pos- 
sible, and  the  infected  area  disinfected  by  antiseptic  solutions.  Carbolic 
acid  and  peroxide  of  hydrogen  are  probably  more  effective  agents  for  this 
])urpose  than  corrofiive  sublimate.  Antiseptic  baths  may  be  used,  the 
limb  being  submerged  for  half  an  hour  once  or  twice  a  day  in  weak  anti- 
septic solutions. 

When  pus  forms  in  the  orbit,  it  is  necessary  to  make  an  early  and 
deep  dissection  in  order  to  reach  the  point  of  infection  and  prevent  grave 
injury  to  the  optic  nerve. 

Erysipelas  is  now  generally  recognized  as  a  contagious  disease,  and  it 
is  therefore  important  that  early  attention  should  be  given  to  the  isola- 
tion of  the  patient  from  other  surgical  patients,  and  great  care  should  be 


42G  TRAUMATIC  FEVER,  ERYSIPELAS,  AND   TETANUS. 

exercised  by  the  surgeon  and  liis  assistants  to  avoid  tiie  transmission  of 
the  disease  to  others.  In  hospitals  such  cases  should  be  transferred  to  a 
special  ward  and  placed  under  the  charge  of  a  member  of  the  staff  spe- 
cially selected  for  the  j)urpose.  In  no  case  is  careful  attention  to  the 
hygienic  surroundings  of  the  patient  of  greater  ini})ortance.  A  thorough 
ventilation  of  the  apartment  and  frequent  change  of  the  clothing  and 
liedding  are  jirecautions  which  may  serve  to  favor  the  removal  of  the 
germs  of  the  disease  as  they  accumulate  and  to  ward  off  a  reinfection  of 
the  patient.  Relapses,  M'hicli  are  so  characteristic  of  erysipelas,  may  in 
this  way  frequently  l)e  avoided.  The  patient  should  not  be  released  from 
his  isolation  until  ail  tendency  to  desquamation  has  ceased. 

HI.  Tetanus. 

Tetanus  is  an  infectious  disease,  generally  traumatic  in  origin,  charac- 
terized by  painful  contractions  of  the  muscles,  beginning  with  those  of 
the  jaw  or  the  neck  and  affecting  progressively  the  muscles  of  the  trunk 
and  the  extremities.  It  is  accompanied  by  convulsive  paroxysms,  and 
is  due  to  the  presence  of  a  bacterial  poison  in  the  blood  and  tissues. 

Etiology. — The  bacillus  tctani  was  first  discovered  in  1885.  It  is  a 
very  slender  rod  with  somewhat  rounded  ends.  Spore-formations  which 
are  spherical  in  form  take  place  at  one  end  of  the  rod,  and,  l)eing  con- 
.siderably  greater  in  diameter  than  the  rod,  give  to  the  Ijacillus  a  drum- 
.stick  or  pin  shape.  It  is  a  strictly  anaerobic  organism,  and  grows  at  a  room 
temperature  in  the  usual  culture  media.  It  rapidly  dies  when  ex})osed  to 
the  air.  Spores  are  formed  in  cultures  kept  in  the  incubating  oven  at  36°  C. 
at  the  end  of  thirty  hours.  The  spores  retain  their  vitality  in  a  desic- 
cated condition  for  several  months.  The  bacillus  is  colored  by  methyl-blue 
and  fuchsin.  The  method  of  Ziehl  may  be  employed  for  doulile  staining 
of  bacilli  and  spores.  It  can  be  cultivated  in  cultures  of  gelatin  mixed 
with  grape-sugar.  In  stal)-cultures  development  takes  place  along  the 
line  of  puncture  a  considerable  distance  below  the  surface  in  innumera- 
ble radiations,  giving  the  apjiearance  of  an  inverted  fir  tree. 

Through  the  researches  of  Brieger  and  Kitasato  a  toxic  substance  has 
been  obtained  called  hianhi.  This  substance  has  been  obtained  not  only 
from  cidtures,  but  from  the  tissues  and  blood  of  individuals  affected  with 
tetanus.  A  substance  known  as  tetanoioxin  and  also  as  yxtsmotoxin  has 
also  been  obtained. 

The  organism  is  found  principally  in  the  tissues  near  the  wound, 
and  rarely  in  the  blood,  the  internal  organs,  or  the  central  nervous 
system.  Injected  into  animals,  the  organism  produces  symptoms  of 
tetanus  in  twenty-four  hours,  and  at  the  autopsy  a  slight  infiltration 
is  seen  at  the  point  of  injection,  but  no  coarse  ])athological  changes  are 
found  elsewhere.  Few  bacilli  are  found,  and  the  symptoms  produced 
are  consequently  ascribed  to  the  tetanin,  which  is  supposed  to  disseminate 
itself  tlu'ougli  the  body. 

The  bacilli  are  found  in  the  superficial  soil  in  temperate,  and  par- 
ticularly in  tro]iical,  regions,  in  the  nnid  of  the  streets,  in  garden  soil, 
and  in  crumbling  masonry,  and  they  have  been  observed  frequently 
in  manure.  Although  so  widely  distributed,  these  organisms  are  rarely 
able  to  exert  their  pathogenic  action,  owing  to  their  anaerobic  nature. 


TETANUS.  427 

It  is  only  in  deeply-punctured  wounds,  tlicrefore,  that  we  find  the  con- 
ditions fuvurable  for  their  growth. 

Among  tlie  predisposing  causes  of  tetanus  meteorological  influences 
have  been  supposed  to  i)lay  an  important  jiart.  Epidemics  of  tetanus 
are  reported  as  following  a  sudden  change  of  weather  after  great  battles. 
In  tropical  countries  the  type  of  the  disease  is  said  to  be  much  more 
virulent. 

Injuries  of  nerves  have  been  supposed,  by  older  writers,  to  give  rise 
to  tetanus,  and  the  disease  has  been  sup|)(jsed  to  follow  injuries  to  cer- 
tain portions  of  the  body,  as  the  hands  and  feet ;  but  statistics  do  not 
appear  to  support  these  views,  for  the  disease  is  known  to  occur  after 
injury  in  almost  every  locality,  and  has  even  occurred  where  no  appre- 
ciable lesion  could  be  found. 

Age  appears  to  exert  a  certain  influence.  Yandell  found  that  in  7 
per  cent,  of  the  cases  collected  by  liim  the  patients  were  under  ten  years 
of  age.  These  figures  do  not  include  cases  of  trismus  nascentiimi.  The 
disease  is  said  to  be  rare  among  the  aged. 

Although  cases  of  idit)pat]nc  tetanus  are  occasionally  repoited,  it  is 
probable  that  the  disease  is  always  traumatic,  the  point  of  inoculation 
being  so  small  as  frequently  to  escape  notice. 

Varieties. — Tetanus  is  both  acute  and  chronic.  Puerperal  tetanus 
and  trismus  naseentium  are  usually  considered  separately  from  traumatic 
tetanus,  but  are  etiologically  in  no  way  to  be  distinguished  from  this 
form  of  the  disease. 

Acute  tetanus  usually  appears  during  the  first  week  after  the  infliction 
of  the  wound.  In  chronic  tetanus  the  symptoms  are  found  in  the  second 
week,  and  sometimes  even  later  than  the  fourteenth  day. 

Symptoms. — After  a  comfortable  night's  rest  the  patient  usually 
wakes  with  the  sensation  of  having  taken  cold.  He  complains  of  a 
stifl'  neck,  but  attaches  no  importance  to  tlie  symptom.  During  the  day 
there  is  a  slight  stiffness  of  the  muscles  of  the  jaw  which  makes  it 
diflicult  for  Jiim  to  open  his  mouth.  The  muscular  rigidity  is  presently 
followed  by  jiowerful  muscular  contractions,  which  soon  become  so  pain- 
ful and  continuous  that  the  jaw  cannot  be  ojiened,  and  considerable 
difliculty  is  experienced  in  swallowing  even  liquids.  The  masseters  are 
found  to  be  in  a  state  of  rigid  contraction  (trismus  or  lockjaw),  and  the 
muscles  in  the  back  of  the  neck  are  so  unyielding  that  it  is  difficult  to 
ap})roximate  the  chin  to  the  sternum.  Tlie  nmsdes  in  the  abdominal 
parietes  are  soon  found  to  be  firm  and  rigid,  and  toward  the  end  of  the 
first  da}'  the  muscles  of  the  back  will  also  become  involved,  producing 
arching  of  the  spine,  or  opisthotonos.  The  muscular  contractions,  which 
are  now  almost  continuous,  are  kno\\n  as  tonic  contractions.  Attempts 
to  swallow  are  painful  and  inefft'ctual,  owing  to  the  paroxysmal  increase 
in  the  muscular  contraction.  The  patient  usually  suffers  from  retention 
of  urine. 

On  the  second  day  the  jaws  are  locked  as  firmly  as  before,  and  nearly 
all  the  muscles  of  the  body,  except  those  of  the  upper  extremities,  are 
involved.  The  arms  are  only  partially  affected,  liut  the  lower  extremities 
are  usually  rigidly  extended.  The  uuiscles  of  the  face  are  also  now 
affected,  the  eyelids  are  contracted,  the  nostrils  raised,  and  the  mouth 
puckered  in  such  a  way  as  to  give  a  peculiar  expression  to  the  patient 


42.S  TRAUMATIC  FEVER,  ERYSIPELAS,   AND   TETANUS. 

(risus  sardonicus).  The  eyes  arc  drawn  in  and  are  j^artially  clo.setl,  and 
occasionally  there  is  strabismus. 

Any  disturbing  influence  brings  about  an  exacerbation  of  the  mus- 
cular spasm  which  exists  throughout  the  body.  The  muscular  conti-ac- 
tions  are  exceedingly  painful,  and  any  attempt  to  jirevent  them  or  to 
straighten  a  liml)  may  lead  to  rupture  of  the  nuiscular  filjre. 

Tiie  attitude  of  the  patient  in  bed  is  characteristic.  He  lies  usually 
upon  his  side,  and  is  apparently  motionless.  Close  inspection  M'ill,  how- 
ever, show  that  the  head  is  drawn  rigidly  backward  and  that  the  arch  of 
the  spine  is  greatly  increased.  The  rigidity  of  the  nuiscles  of  the  mouth 
does  not  permit  distinct  articulation,  and  the  patient  emits  only  muffled 
groans  in  answer  to  questions.  The  spasm  of  the  sphincters  renders 
movements  of  the  bowels  and  evacuation  of  the  bladder  extremely 
difficult. 

There  is  but  little  pyrexia  at  first,  and  there  is  usually  no  character- 
istic temperature-curve.  There  may  be  a  rise  of  temperature  during  the 
later  stages  of  the  disease,  and  even  post-mortem.  Diajdioresis  is  a 
marked  feature  of  the  disease,  occurring  principally  after  each  convul- 
sion, and  doulitless  aids  in  preventing  an  excessive  rise  of  temperature. 

But  little  sleep  is  obtained,  owing  to  the  almost  continuous  muscular 
contraction.  Short  periods  of  slumber  may  be  secured  by  the  use  of 
drugs,  but  the  patient  is  soon  roused  Ijy  renewed  convulsive  movements. 
During  these  attacks,  which  last  usually  a  few  seconds  oidy,  there  are 
some  cyanosis  of  the  face  and  foaming  at  the  mouth.  There  is  also 
marked  dyspnoea  ;  the  pulse  is  greatly  accelerated ;  the  muscular  con- 
tractions usually  produce  at  this  time  a  marked  opisthotonos. 

Attempts  to  swallow  often  bring  on  spasm  of  the  glottis,  and  death 
has  occurred  during  such  a  crisis.  Sjiasm  may  also  be  produced  by 
attempts  to  expectorate  the  mucus  which  has  accumulated  in  the  throat. 
As  the  result  of  these  constant  muscular  etforts  and  the  loss  of  udurish- 
ment  and  sleep  thei'e  is  great  prostration.  The  face  is  pale  and  emaciated, 
and  if  not  convulsed  there  is  an  expression  of  great  apprehension.  The 
voice  is  feeble,  and  the  skin  is  constantly  bathed  in  sweat.  The  mind  is 
clear,  and  the  patient  is  fully  sensible  to  the  agony  of  his  disease.  Dur- 
ing the  last  moments  the  tetanic  spasms  may  relax,  but  they  are  usually 
maintained  imtil  the  end. 

In  chronic  tetanus  the  period  of  incubation  is  longer  than  that  of 
acute  tetanus,  the  first  symptoms  appearing  usually  in  the  second  or  third 
week  after  the  injury.  The  order  in  which  the  symptoms  appear  is  the 
same  as  in  acute  tetanus.  The  development  of  the  early  symptoms  may 
also  be  as  rapid  as  in  the  acute  form,  but  there  are  frequent  periods  dur- 
ing which  the  patient  obtains  a  respite  from  the  nuiscular  contractions. 
During  these  intervals  the  patient  is  able  to  take  nourishment,  and  his 
strength  is  corresj)ondingly  maintained.  As  time  passes  these  intervals 
become  longer  and  the  muscular  spasms  are  less  severe,  and  the  jjatient 
has  an  opjiortunity  to  obtain  sleep.  Prostration  is,  however,  extreme, 
and  any  mmsual  excitement  or  irritation  lirings  back  the  spasms.  The 
period  of  convalescence  is  liable  to  be  interrupted  by  numerous  relapses. 
The  disease  is  likely  to  be  greatly  prolonged  in  this  way. 

Head  Tetanus  occurs  after  injuries  in  the  region  of  distribution  of  the 
cranial  nerves.     It  is  chai'acterized  by  spasm  of  the  pharyngeal  muscles 


TETANUS.  429 

and  paralysis  of  the  facial  nerve.  There  is  also  trismus,  and  occasion- 
ally tetanic  contractions  of  the  muscles  of  the  neck  and  abdomen.  This 
form  of  tetanus  occurs  usually  after  a  \vound  in  the  fiicc.  The  difticulty 
in  swallowing  has  given  rise  to  the  term  "tetanus  hydropliobicns." 
Like  other  forms  of  tetanus,  it  may  be  either  acute  or  chronic. 

Tliere  is  nothing  characteristic  in  the  condition  of  the  wound.  Ac- 
cording to  Poncet,  the  suppurative  process  is  less  healthy  in  character 
and  the  tissues  appear  to  be  in  a  state  of  irritation.  Occasionally  a  slight 
blush  is  seen  along  the  edges  of  tlie  wound,  or  there  may  be  evidence 
of  a  lymphangitis.  Occasionally  a  slight  pricking  sensation,  and  even 
pain,  is  experienced  in  the  alFected  limb.  Experiments  by  Buschke  and 
Oergel  show  that  granulation  tissue  taken  from  the  wound  of  a  boy  who 
died  from  tetanus,  and  inoculated  into  mice  produced  symptoms  of  teta- 
nus with  a  fatal  result. 

Wounds  of  the  extremities  are  said  to  be  more  frequently  followed 
by  tetanus  than  those  of  any  other  region.  This  is  borne  out  by  the 
observations  of  Yandell  and  the  statistics  given  in  the  Surgical  History 
of  the   War  of  the  Rebellion. 

This  a[)parent  preference  of  locality  is  probably  due  to  the  fact  that 
punctured  woinids  are  more  frequent  in  the  hands  and  feet.  The  ])res- 
ence  of  a  foreign  body  is  supposed  to  lie  a  jiredisposing  cause,  lint  teta- 
nus may  follow  even  slight  injuries.  The  fact  that  tetanus  is  frequent  in 
military  surgery  is,  however,  due  not  only  to  the  penetrating  nature  of 
the  wounds,  Ijut  also  to  the  frequent  presence  of  a  foreign  body. 

Post-mortem  Changes. — Evidence  of  intlammation  of  the  brain 
and  meninges  is  wanting,  but  signs  of  intlammatiiin  in  the  nerves  and 
in  the  cells  of  the  metlulla  and  cord  ha\-e  been  observed.  Grinelle  in  an 
analysis  of  52  cases  reports  that  29  presented  lesions  in  tiie  cord  and 
membranes,  in  3  changes  were  noticed  in  the  brain,  and  in  11  in  the 
nerves  and  muscles.  Loekhart  Clarke  found  a  disintegration  and  soft- 
ening of  a  jjortion  of  the  gray  substance  of  the  cord.  Ranvier  was, 
however,  unable  to  find  any  pathological  changes  in  the  cord  in  four 
cases  of  tetanus.  Laveran  found  connective-tissue  changes  in  the  tibial 
nerve  of  a  patient  who  died  of  tetanus  following  amputation  of  the  leg. 
Jewell  thinks  the  principal  seat  of  the  disorder  is  in  the  posterior  cornua 
and  the  contiguous  central  gray  matter. 

Diagnosis. — The  diagnosis  of  tetanus  may  be  difficult  in  the  earlier 
stages  of  tlie  disease.  Stillness  of  tlie  muscles  of  the  neck  and  jaws  may 
be  due  to  inflammatory  affections  of  the  mouth  or  teeth  or  to  abscess  of  tiie 
cervical  glands.  Rheumatic  inHannnation  of  the  temporo-maxillarv  artic- 
ulation is  usually  accompanied  by  sufficient  signs  of  local  inflammation 
to  be  readily  recognized.  Hysterical  contraction  of  the  masseter  mus- 
cles is  not  liable  to  give  rise  to  a  mistake  in  diagnosis,  as  sufficient  time 
will  usually  have  elapsed  to"  enable  the  surgeon  to  exclude  tetanus. 
Temporary  spasms  following  tlie  dressing  of  a  painful  wound  are  not 
likely  to  Ije  mistaken  for  tetanus. 

Cases  of  tetanic  spasm  due  to  peripiieral  irritation  by  scars  or  foreign 
bodies  are  reported,  and  in  some  instances  terminate  fatally.  Some 
of  these  cases  may  be  true  tetanus,  but  others  are  probably  examples  of 
severe  reflex  irritation. 

In  cases  of  strychnia-poisoning  there  is  spasm  of  the  muscles  of  the 


4;50  TRAUMATIC  FEVER,  ERYSIPELAS,  AND   TETANUS. 

limbs  and  body,  with  acliing  of  the  back  and  laryngismus.  The  per- 
sistency of  the  spasm  depends,  however,  upon  the  frequency  of  the  dose. 
A  characteristic  feature  of  strychnia-poisoning  is  hypertesthesia  of  the 
retina,  and  objects  are  seen  green  in  color. 

Tetany  is  not  often  seen  in  this  country  :  it  affects  young  persons 
chiefly,  and  consists  in  tonic  sj)asnis  of  various  groups  of  muscles,  most 
often  those  of  the  upper  extremity.  Opisthotonos  may  occur,  but  there 
is  never  trismus.  The  attacks  are  short  and  more  or  less  localized,  and 
Trousseau's  symptom,  seen  in  no  other  convulsive  disease,  is  always 
present,  pressure  upon  the  n(>rve-trunk  leading  to  the  affected  group 
of  muscles  always  bringing  on  a  cliaracteristic  attack. 

Prognosis. — Acute  tetanus  is  one  of  the  most  fatal  of  diseases,  but 
in  cln-onic  tetanus  the  percentage  of  mortality  is  very  much  less.  The 
longer,  therefore,  the  patient  lives,  the  greater  are  his  chances  of  recov- 
ery. Yandell  in  a  study  of  415  cases  noted  a  marked  falling  off  in  the 
number  (jf  deaths  on  the  fifth  day,  after  which  period  the  mortality 
steadily  diminished. 

Tetanus  occurring  in  military  surgery  appears  to  be  unusually  fatal. 
In  the  Surgical  History  of  the  War  of  the  RcbcUion  505  cases  are  recorded, 
the  mortality  being  89.3  per  cent.  Of  Yandell's  cases,  which  wei'e  col- 
lected from  various  soui-ces,  213  recovered  and  182  died.  The  date  of 
the  first  appearance  of  the  disease  is  a  sign  of  prognostic  value.  Yan- 
dell found  that  where  the  symptoms  were  delayed  until  the  fourteenth 
day  from  the  time  of  injury  the  recoveries  exceeded  the  deaths. 

The  gravity  of  the  wound  does  not  appear  to  have  any  influence 
upon  the  severity  of  the  disease.  In  tropical  climates  the  disease  is 
much  more  fiital  than  in  the  temperate  zones. 

Treatment. — In  estimating  the  value  of  any  particular  drug  it  is 
important  to  remember  the  statement  of  Yandell,  that  when  tetanus 
continues  fourteen  days  recovery  is  the  rule  and  death  the  exception, 
apparently  inde])cndent  of  treatment. 

Yandell  places  chloroform  at  the  head  of  the  list  of  drugs  in  cases 
of  acute  tetanus.  The  weight  of  evidence  appears  to  be  in  favor  of 
the  sedative  action  of  this  drug  upon  the  nervous  system.  It  may  be 
administered  by  inhalation,  eitlier  to  the  point  of  anajsthesia  or  a  napkin 
may  be  placed  upon  the  chest  of  the  patient,  who  is  thus  exposed  to  the 
influence  of  the  drug.  Its  action  is  not,  however,  so  enduring  as  that 
of  chloral. 

Chloral  seems  to  be  most  efficacious  in  chronic  tetanus.  It  appears 
to  act  by  diminishing  reflex  excitability  in  the  nerve-centres ;  it  relieves 
pain  and  prevents  spreading  of  the  muscular  spasm  and  the  recurrence 
of  the  convulsions.  It  may  be  continued  for  one  or  two  weeks  at  a 
time,  and  in  this  way  an  almost  permanent  sleep  may  be  maintained, 
which  paves  the  way  to  convalescence.  In  doses  of  100  to  200  grains 
a  day  it  will  relieve  muscular  spasm  in  acute  tetanus,  but  it  does  not 
appear  to  have  any  appreciable  effect  upon  the  mortality. 

Opium,  when  used,  must  be  given  in  large  doses  to  control  the  spasm, 
and  the  digestive  disturbance  caused  by  the  drug  is  a  contraindication  to 
its  use. 

Bromide  of  potassium  can  be  given  in  connection  with  chloral,  or  in 
the  convalescent  stage  as  a  substitute  for  that  drug,  but  it  is  altogether 


TETANUS.  431 

too  mild  a  remedy  to  produce  an  appreciable  effect  in  the  more  active 
stages  of  the  disease. 

Calabar  bean,  or  its  active  principle,  when  given  in  small  doses, 
I'elieves  the  muscular  contraction  ;  the  jaws  relax,  and  the  head  reposes 
quietly  upon  tlie  jjillow.  If  given  in  large  doses,  the  spasms  appear  to 
be  greatly  aggravated.  Poncet  explains  the  favorable  action  of  the  drug 
by  its  eifect  upon  the  conductibility  of  the  motor  nerves  by  which  the 
muscular  system  is,  as  it  were,  isolated  from  the  nerve-centres.  He 
prefers  to  give  it  by  the  mouth  rather  than  In'  subcutaneous  injectii)n, 
as  the  dose  can  be  more  carefully  regulated  and  the  action  of  the  drug 
observed  by  tills  method.  From  |  to  1  grain  of  the  extract  may  be  given 
by  the  mouth  every  four  hours,  and  15  to  20  drops  of  a  1  per  cent, 
solution  may  be  injected  subcutaneously.  The  statistics  of  Knecht  give 
a  mortality  of  45  per  cent,  in  60  cases  in  which  this  drug  was  used. 

Warm  baths  and  dia}ilioretics  have  been  used  extensively  in  the 
treatment  of  tetanus,  doubtless  in  imitation  of  Nature's  method  of  giv- 
ing rebel",  as  diajihoresis  is  a  frequent  symjitom  of  the  disease.  Vapor 
baths  are  probably  the  most  efficacious  way  of  carrying  out  this  treat- 
ment, as  they  are  less  likely  to  disturb  the  patient  and  thus  aggravate 
symptoms.  In  no  disease  should  the  comfort  of  the  patient  be  so  care- 
fully studied,  and  every  eifort  should  lie  made  to  avoid  disturbance  or 
irritation  of  any  kind.  The  value  of  skilled  nursing  is  shown  nowhere 
to  greater  advantage  tlian  in  tliis  disease. 

Due  attention  siiould  be  given  to  the  wound,  and  an  eifort  shoidd  be 
made  thoroughly  to  disinfect  it.  The  wound  should  consequently  be 
laid  open,  and  its  surfaces  not  only  exposed  to  the  action  of  oxygen, 
but  to  powerful  antiseptics,  as  in  this  way  the  amount  of  the  virus  may 
possibly  be  diminished.  Punctured  wounds  should  be  opened  sufficiently 
to  admit  of  thorough  disinfection.  It  is  possible  that  the  present  asep- 
tic method  may  permit  the  early  closing  erf  a  punctured  wound,  and 
thus  favor  the  development  of  the  tetanus  bacilli  in  the  deeper  layers 
of  the  wounded  part.  The  old-fashioned  poultice  by  setting  up  suppu- 
ration ftvvored  a  discharge  of  all  poisonous  material.  In  some  cases  the 
scar  is  red,  tender,  and  swollen.  Such  scars  should  be  excised,  and  in 
all  cases  it  is  advisidde  to  open  and  explore  the  cicatrix,  as  in  some 
instances  particles  of  dirt  have  been  removed  with  the  cicatricial  tissue. 

Experiments  u])on  animals  have  shown  that  immunity  can  be  obtained 
by  inoculations  with  minute  doses  of  the  poison  or  with  a  filtrate  Avhich 
has  been  exposed  to  a  temjjcrature  sufficient  to  destroy  its  activity  (Kita- 
sato).  Immunity  was  also  obtained  for  a  certain  time  by  inoculating 
animals  with  the  filtrate  from  the  culture  of  the  tetanus  bacillus,  and 
subsequently  by  inoculating  them  at  the  same  point  with  a  solution 
of  terchloride  of  iodine.  It  was  further  found  that  the  blood-serum 
of  an  immune  animal  when  injected  into  another  animal  protected  it 
from  the  effects  of  the  inoculation  with  the  tetanus  bacillus,  and  that 
inoculated  animals  in  whom  the  tetanic  symptoms  had  already  made 
their  appearance  were  preserved  from  death  by  the  injection  of  the 
blood-serum  of  an  immune  animal  (yternberg).  Tizzoni  and  Cattani 
gave  the  name  "  tetanus  antitoxine "  to  the  substance  existing  in  the 
blood  of  an  immune  animal  which  produced  these  results.  Behring 
found  that  the  more  intensely  the  animal  was  inoculated  to  render  it 


432  TRAUMATIC  FEVER,  ERYSIPELAS,  AND  TETANUS 

immune,  and  the  longer  it  liad  remained  inoculated,  just  so  much  less 
of  its  serum  was  required  to  cause  iiunuiiiity  in  another  animal.  A 
more  powerful  dose  was,  however,  required  for  therapeutic  purposes  to 
check  tetanus  which  had  already  made  its  appearance. 

These  interesting  experiments  have  led,  as  yet,  to  a  limited  employ- 
ment only  of  the  antitoxine  in  the  treatment  of  tetanus  in  man.  A 
number  of  successful  cases  have  been  reported,  Init  the  treatment  seems 
to  have  been  employed  almost  invariably  in  chronic  tetanus.  In  a  case 
reported  by  Rotter  treatment  was  not  begun  until  the  fourteenth  day  of 
the  disease  :  36  grammes  of  blood-serum  from  an  immunized  horse,  with 
5  per  cent,  of  carbolic  acid,  were  injected  into  the  back.  The  injections 
were  continued  for  five  days,  and  the  patient  recovered,  the  symptoms 
rapidly  yielding  to  the  treatment. 


RABIES;    HYDROPHOBIA;  LYSSA. 

By  HERMANN  M.  BIGGS,  M.  D. 


Rabies  is  an  acute  infectious  disease  occurring  in  many  species  of 
animals  and  in  man.  It  is  transmitted  solely  by  inoculation  from  an 
infected  animal,  usually  through  a  bite,  and  is  characterized  by  a  long 
period  of  incubation,  paroxysmal  convulsions,  great  mental  disturljance 
and  excitement,  fever,  often  l)y  general  motor  paralysis,  and  terminates 
almost  invariably  in  death.  Wiien  rallies  occurs  in  man  it  is  connnonly 
called  hydrophobia,  because  of  peculiar  spasms  of  the  muscles  of  the 
throat  whi(^li  follow  any  attempts  at  deglutition,  or  which  may  occur 
even  at  the  sight  of  water  or  food.  These  are  extremely  ]iainful  and 
produce  great  terror  in  the  patient,  and  Jienee  the  name  "hydrophobia." 

Rabies  ix  Animals. — Rabies  may  occur  in  many  species  of  animals 
besides  dogs,  especially  in  those  of  the  canine  genus,  wolves  and  foxes, 
and  in  skiudvs.  Cats  are  sometimes  aifected,  although  less  commonly 
than  dogs.  It  may  also  be  transmitted  to  herbivora — to  horses,  cattle, 
sheep,  goats,  rabbits,  pigs,  guinea-pigs — and  less  readily  to  other  species 
of  animals,  either  ex])eriuientally  In'  inoculation  or  through  the  bites  of 
rabid  dogs.  .Vdami  has  reported  a  very  extensive  epidemic  of  ral)ies 
which  occurred  in  1885  among  the  deer  in  Richmond  Park  in  England 
and  afterward  in  the  park  of  the  marquis  of  Bristol.  Rabies  is  rarely 
transmitted  from  other  animals  than  those  of  the  canine  genus. 

In  dogs  the  symjitonis  of  rabies  vary  somewhat,  but  the  first  real 
symptom,  usually  not  noticed,  is  a  rise  in  temperature.  This  is  fol- 
lowed by  dnlness,  with  an  indisposition  to  move;  later,  the  animal 
becomes  shy,  suspicious,  restless,  and  irrital)le,  often  snapping  at  any- 
thing which  comes  near.  At  tliis  period  he  frequently  leaves  home  if 
he  is  not  confined,  and  may  make  long  excursions,  sna])ping'at  everv- 
tiiing  in  his  way,  and  particularly  attacking  other  dogs  or  animals. 
Tln-oughout  this  early  period  there  is  a  depraved  appetite,  the  animal 
rejecting  tiie  usual  food  and  devouring  hay,  cloth,  wood,  coal,  gravel, 
fiecal  matter,  or  even  its  own  hair  or  tail.  This  symptom  is  important 
and  rather  characteristic,  although  it  is  by  no  means  pathognomonic,  for 
frequently  it  may  be  seen  in  other  diseases  than  rabies.  Almost  in\'ari- 
ably  the  bark  is  altered  ;  it  is  hoarse,  unlike  its  usual  tone,  and  ter- 
minates with  a  peculiar  howl.  In  one  variety  of  the  disease  in  dogs 
there  is  intense,  almost  maniacal,  excitement  ;  in  another  there  is  early 
paralysis  of  the  muscles  of  the  jaw  (so  that  it  hangs  down  and  allows 
frothy  saliva  to  escape  from  the  mouth),  followed  by  general  motor 
paralysis.  In  all  varieties  there  is  commonly  weakness  of  the  muscles 
of  deglutition  :  this  interferes  \vith  swallowing,  but  at  no  time  in  the 
disease  is  there  any  fear  of  water.     A  rabid   dog  will   often  plunge  his 

Vol.  I.— 2S  433 


434  BABIES;   HYDBOPIIOBIA;   LYSSA. 

nose  and  partially  suhmergo  his  head  in  a  disji  of  water  or  in  rnnning 
water.  There  exists  a  popnlar  and  danujeroiis  fallacy  rejjardino  tliis  fear 
of  water,  wiiich  is  no  doubt  based  on  tiie  name  "  hydro]iliol)ia."  It  is 
eoninionly  believed  by  the  laity  that  a  dog  cannot  be  rabid  if  he  drinks 
or  submerges  his  head  in  water. 

After  a  longer  or  shorter  period,  in  all  cases  paralysis  appears,  and 
the  dog  staggers  in  attempts  to  walk,  and  often  falls.  Finaliv,  tlie 
weakness  in  the  legs  becomes  so  marked  tliat  the  animal  is  unal)le  to 
stand,  and  dies  completely  paralyzed.  A  distinction  has  often  been 
made  between  dumb  or  paralytic  and  furious  rabies,  but  the  difference 
is  largely  one  of  degree  of  excitement,  which  may  depend  upon  the 
conditions  surrounding  the  animal  in  the  early  part,  and  the  rapidity  of 
the  course,  of  the  disease.  In  every  case,  ultimately,  there  is  paralysis 
more  or  less  complete.  A  change  in  the  disposition  oi'  an  animal,  siiy- 
ness,  restlessni^s,  illusions  of  sight  and  heai'ing  (shown  by  sna]iping  at 
invisible  objects  in  .the  air,  elevation  of  the  ears,  an  attentive  j)osition, 
due  to  the  hearing  of  sounds  which  do  not  exist),  perversion  of  appe- 
tite, wandering  from  home,  and  similar  modifications  of  the  nsual 
apj)earancc,  action,  and  manner,  are  all  symptoms  suggestive  of  the  dis- 
ease in  the  early  stage. 

It  is  an  important  point  to  determine  when  a  raljid  animal  can 
transmit  the  disease.  Experimental  observations  have  shown  that 
there  is  commonly  an  elevation  of  temjierature  in  dogs  before  any 
other  symptoms  of  the  disease  appear,  and  at  this  time,  and  even  per- 
haps for  twenty-four  or  forty-eiglit  hours  or  more  before  tlie  elevation 
of  temjK'ratui-e,  the  l)ite  of  tlie  animal  may  be  virulent.  In  this  way 
are  explained  the  eases  of  rabies  which  have  been  reported  as  resulting 
from  the  bites  of  animals  ajiparently  in  perfect  health,  and  to  this,  no 
doubt,  is  due  the  belief  which  formerly  existed  that  nnder  certain  con- 
ditions the  bites  of  animals  might  produce  hydrophobia  wlien  they  them- 
selves \\ere  not  affected  by  the  disease. 

Kabies  in  dogs  almost  invariably  terminates  fatally.  There  are, 
however,  some  very  rare  cases  in  which  recovery  occurs.  The  duration 
of  the  disease  is  variable,  sometimes  death  occurring  in  twenty-four  or 
thirty-six  hours,  while  in  other  cases  it  is  postponed  for  seven,  or  even 
very  rarely  for  nine  or  ten,  days,  \yhen  a  person  has  been  bitten  by  a 
dog,  whether  suspected  of  being  rabid  or  not,  instead  of  destroying  the 
dog  innnediately,  as  is  too  frequently  done,  the  animal  should  be  placed 
in  confinement  and  kt'jit  under  observation  for  several  weeks  if  necessary, 
so  that  it  may  be  witli  certainty  determined  whether  the  dog  was  or  was 
not  rabid.  If  the  dog  is  destroyed,  it  is  of  course  impossible  to  determine 
whether  it  was  ral)id  or  not,  except  by  the  inoculation  of  other  animals, 
by  the  subdural  method  of  Pasteur,  witli  the  medulla  or  spinal  cord.  As 
will  lie  seen  later,  however,  a  jimliable  diagnosis  can  frequently  be  based 
upon  the  autopsy-findings  and  the  microscopical  examination  of  certain 
portions  of  tlie  brain. 

In  the  rabbit  the  sym])toms,  as  produced  by  inoculation,  commonly 
resemble  those  of  dumb  or  paralytic  rabies  as  it  occurs  in  dogs.  They 
are  not  unlike  those  found  in  the  human  being  in  acute  ascending 
paralysis,  and  consist  in  dulness  with  some  pyrexia,  followed  by  weak- 
ness in  the  hind  legs,  which  gradually  increases  and  extends  for\vard 


DISTRIBVTIOX  AND  FREQUENCY.— ETIOLOGY.  435 

until  a  complete  jicneml  paralysis  results.  Tiie  animal  lies  tlicn  upon 
its  side,  with  dittieult  and  labored  respiration  and  complete  motor 
paralysis. 

The  period  of  incubation  in  animals  is  exceedingly  variable,  espe- 
cially when  the  disease  is  produced  by  subcutaneous  inoculation.  It 
varies  from  seven  or  eight  days  to  a  month  or  more.  In  the  subdural 
method  of  inoculation  of  Pasteur,  after  the  virus  has  been  passed  through 
a  series  of  rabbits  the  period  of  incubation  in  tliese  animals  l)ecomes  per- 
manently shortened  to  about  seven  days,  and  remains  uniform  at  this 
point  when  the  inoculations  are  made  by  this  method. 

Distribution  and  Frequency. — For  a  long  time  it  was  assumed 
that  ral)ies  \vas  confined  to,  cir  was  chiefly  found  in,  temperate  regions. 
Furtlier  observation  lias  shown,  however,  that  it  occurs  in  all  parts  of 
the  world,  excei)ting  perliaps  in  Australia,  New  Zealand,  and  one  or  two 
other  isolated  localities  wliere  it  apparently  has  not  yet  been  introduced. 
The  frequency  with  which  the  disease  occurs  varies  greatly.  Like  other 
epizootic  diseases,  it  often  appears  in  epidemic  form.  It  can  be  entirely 
eradicated  by  the  efficient  enforcement  of  a  law  ]>roviding  for  the  muzzling 
of  dogs.  Rabies  has  bec(jme  practically  an  unknown  disease  in  many 
parts  of  Germany  ami  some  other  Eurojiean  countries  as  the  result  of 
properly  enforced  laws  regarding  nuizzling. 

Under  all  conditions  rabies  is  a  comparatively  rare  disease  in  man. 
Boudin,  in  a  communication  to  the  Frencii  Academy  in  1863,  gave  the 
number  of  deaths  from  iivdrop]iol)ia  in  Prussia,  from  1854  to  1858,  as 
196  ;  in  Belgium,  from  1856  to  1860,  as  26  ;  in  England,  from  1853  to 
1857,  as  100  ;  in  Scotland,  from  1855  to  1S63,  10  ;  in  Sweden,  from  1856 
to  1860,  as  42.  In  Ireland  the  nmnber  of  deaths  for  ten  years  ending 
in  1879  was  21  ;  in  London,  according  to  the  Registrar-General's  return, 
thei'e  were  no  cases  from  1856  to  1862,  2  in  1863,  none  in  1864,  9  in 
1865,  6  in  1866,  2  in  1879,  3  in  1880,  5  in  1881,  4  in  1882,  8  in  1883, 
9  in  1884,  and  27  in  1885.  Muzzling  was  enforced  in  1886,  and  the 
number  suddcidy  fell  to  !),  all  of  which  occurred  in  the  early  part  of  the 
year.  In  1887  and  ISSS  there  was  not  a  single  death  reported.  The 
number  of  cases  occurring  annually  in  this  country  has  been  very  small, 
although  the  actual  number  cannot  be  determined.  In  New  York  City, 
during  tiie  ten  years  ending  in  1891,  there  were  in  all  9  deaths  reported 
to  tlie  Health  Department  as  being  due  to  rallies.  In  1887  in  the  wliole 
of  tiie  German  Empire  there  were  only  4  deaths  from  rabies.  In  France 
rabies  is  apparently  more  prevalent,  although,  according  to  the  reports 
of  Tardieu  and  Brouardel  for  tiie  years  1850  to  1872,  there  were  in  all 
685  deaths,  an  average  of  a  little  less  than  40  yearly.  Tardieu  says  of 
his  reports  that  nearly  all  departments  replied  to  his  inf|uiries,  and 
Brouardel,  tliat  alxmt  two-thirds  were  included  in  liis.  Since  tlie  pul)lic 
announcement  of  the  discoveries  of  Pasteur  regarding  the  preventive 
treatment  of  rabies,  however,  apparently  the  numlier  of  cases  of  infec- 
tion has  largely  increased,  if  we  are  to  assume  that  all  those  inocadated 
iiad  really  been  bitten  l)y  rabid  dogs,  for  from  1200  to  2000  French- 
men liave  been  inoculated  each  year. 

Etiology  of  Rabies. — Tliere  is  but  one  efficient  cause  of  rabies,  the 
introduction  of  a  specific  virus  derived  from  a  ral)id  animal.  Of  the 
nature  of  this  virus  we  have  as  yet  no  absolute  knowledge,  lint  there 


436  RABIES;  HYDROPHOBIA;   LYSSA. 

can  be  no  I'easonable  donbt,  reasoning  from  analogy,  tliat  it  is  a  niicro- 
organisni  of  some  kind.  Nnmerons  other  causes  liave  been  commonly 
supposed  to  be  efficient  in  the  production  of  the  disease.  There  are 
popular  supei'stitions  to  the  eii'ect  that  the  bite  of  an  angry  dog  or  of 
one  in  rut  may  be  followed  by  rabies,  that  the  disease  is  especially  prev- 
alent during  the  hot  months  of  the  year,  and  that  certain  breeds  of  dogs 
are  particularly  susceptible  to  rabies.  These  superstitions  are  not  at  all 
borne  out  by  experience  or  statistics.  Law  (piotes  statistics  from  Bouley 
showing  that  in  the  winter  months  among  dogs  there  occurred  75i3  cases 
of  rabies ;  during  the  three  spring  montlis,  857  ;  during  the  three  sum- 
mer months,  788  ;  and  during  the  three  autumn  months,  696 ;  which 
indicated  that  the  largest  number  of  cases  occurred  in  the  spring  months, 
but  tliat  there  was  really  little  difference  in  the  ntnnber  of  cases  occurring 
in  any  season  of  the  year. 

There  are  certain  questions  which  arise  in  connection  with  the  etiol- 
ogy of  rabies  which  are  of  importance  and  interest.  The  virus  undoubt- 
edly resides,  particularly  in  dogs,  in  the  saliva  and  salivary  glands. 
The  disease  was  long  ago  produced  in  dogs  by  ^lajendie  by  inoculating 
them  with  the  saliva  of  hydro])h()l)ic  patients  and  of  rabid  dogs. 
Pasteur  has  shown  that  the  virus  exists  after  death  in  the  central 
nervous  system,  particularly  the  medulla  or  sj)inal  cord,  and  also  in 
the  peripheral  nerves,  as  well  as  in  the  salivary  glands,  and  that 
the  disease  may  be  produced  more  certainly  and  with  a  more  uniform 
period  of  incubation  when  inoculations  are  made  beneath  the  dura 
mater  after  tre])hining  the  skull  than  when  they  are  made  by  subcu- 
taneous injection  of  the  virus.  It  is  probable  that  the  disease  may  be 
communicated  from  one  human  being  to  another,  although  no  well- 
authenticated  cases  of  this  sort  have  been  recorded.  JMedical  men  and 
nurses  who  are  in  attendance  on  cases  of  hydrophobia  always  escape, 
although  the  saliva  is  often  thrown  upon  the  faces,  hands,  or  clothing. 
The  virus  is,  as  a  rule,  rajiidly  destroyed  by  decomposition,  although  one 
or  two  cases  have  been  recorded  where  hydrophobia  ajijiarently  resulted 
from  accidental  inoculation  at  the  post-mortem  examination  of  cases 
of  rabies. 

In  a  large  majority  of  all  cases  in  the  human  being  the  disease  is 
contracted  from  the  bite  of  a  dog,  in  a  very  few  cases  from  the  bite 
of  a  cat,  and  occasionally,  especially  in  Russia,  from  the  bite  of  rabid 
wolves  or  foxes.  Bites  on  uncovered  jiarts  of  the  body,  as  upon  the 
face  or  hands,  are  f\ir  more  likely  to  be  followed  b}-  the  disease  than  if 
inflicted  u])on  jjortions  covered  with  clothing,  as  in  the  latter  case  the 
virulent  saliva  is  frequently  entirely  wiped  off  from  the  teeth.  The  dis- 
ease has  l)een  caused  bv  a  rabid  dog  licking  a  scratch  u]ion  the  hand,  and 
apparently  it  has  followed  the  scratch  of  a  rabid  cat,  the  animal's  saliva 
having  been  probably  thus  introduced.  There  is  absolutely  no  reason  to 
suppose  that  the  disease  can  ever  result  from  the  bite  of  any  animal  not 
suffering  ft-om  rabies.  Undoubtedly,  the  cases  in  which  this  is  supposed 
to  have  occurred  have  been  either  otherwise  inoculated  or  have  been 
infected  by  an  animal  apparently  well,  but  in  which  the  s3'mptoms  had 
not  yet  appeared,  as  it  has  been  shown  that  the  saliva  may  be  virulent 
for  several  days  at  least  before  the  appearance  of  the  disease.  A  large 
proportion  of  the  cases  occurring  in  the  human  being  are  in  children, 


INCUBATIOX.  437 

because  tliev  are  more  likely  to  be  bitten,  and  becaose  tliey  are  more 
frequently  bitten  on  exposed  parts  of  the  body.  In  rare  instances  the 
disease  has  l)een  transmitted  to  human  beings  and  to  other  animals  from 
rabid  cattle,  horses,  sheep,  etc.  In  these  animals  the  saliva  may  be  also 
virulent. 

The  saliva  from  rabid  animals  will  retain  its  virulence  for  a  consider- 
able period  after  having  been  dried.  Pasteur  has  shown  that  the  spinal 
cords  of  ri'bid  animals  which  have  been  dried  lose  their  virulence  at  the 
end  of  about  fourteen  days.  Exposure  to  comparatively  low  temj)era- 
tures  also  destroys  the  virulence  of  rabic  virus ;  that  is,  exposure  for 
one  hour  to  a  temperature  of  50°  C.  The  direct  rays  of  the  sun  and 
exposure  to  the  action  of  1  per  cent,  sublimate  solution  or  1  per  cent, 
carbolic  solution  for  three  hours  have  the  same  cflFect.  Byron  has  shown 
that  the  virulence  may  be  preserved  l)y  immersing  the  rabic  spinal  cord 
in  pure  glycerin  or  by  sealing  up  aseptic  pieces  of  the  spinal  cord  in 
test-tubes. 

The  susceptibility  of  animals  to  the  virus  varies  with  the  kind  of 
tissue  into  which  it  is  injected.  Intravenous  injections  are  not  often 
followed  by  the  disease.  Injections  into  the  muscular  tissue  are  more 
freipientlv  followed  bv  infection  than  injections  into  the  subcutaneous 
tissue,  and  the  apjjlication  of  the  virus  to  divided  nerve-filaments  is 
generallv  etficacious  in  ])roducing  the  disease.  Divestin,  Zagari,  Pas- 
teur, and  others  have  apparently  shown  that  the  virus  extends  from  the 
seat  of  infection  along  the  uerve-trunk  to  the  spinal  cord,  and  if  the 
animals  arc  killed  at  the  proper  time  the  virus  may  be  found  in  the 
nerves  leading  from  the  part  infected  when  it  is  as  yet  absent  in  other 
parts  of  the  nervous  system.  Tims  in  bites  of  the  posterior  extremities 
it  is  jn'cscnt  in  the  lumbar  cord  when  absent  in  the  cervical  region  or 
medulla.  It  is  apparently  sometimes  present  in  the  pancreas  and  lach- 
rymal glands,  and  rarely  in  the  secretion  of  the  mammary  glands ;  but 
it  is  usually  absent  from  the  blood,  liver,  spleen,  and  kidneys. 

Incubation.— The  incubation  period  of  rabies  in  dogs  varies  widely. 
The  shortest  period  is  apparently  six  days,  and  the  longest  al)out  eight 
months.  In  the  majority  of  cases  it  varies  between  fourteen  and  thirty 
days.  In  horses,  cats,  sheep,  and  swine  it  is  ordinarily  from  twenty  to 
thirty  days,  but  the  period  may  be  prolonged  considerably  beyond  tliese 
limits.  Bollinger  says  that  in  60  per  cent,  of  all  cases  in  the  human 
subject  it  is  between  eighteen  and  sixty  days ;  in  6  jier  cent.,  between 
three  and  eighteen  days;  and  in  34  ])er  cent,  the  period  is  longer  than 
sixty  days.  Cases  have  been  recorded  where  the  incubation  has  ap})ar- 
ently  been  greatly  prolonged  to  from  one  to  three  or  five  years.  These 
cases,  however,  are  not  well  authenticated,  and  in  well-observed  cases  the 
incubation  rarely,  if  ever,  is  more  than  twelve  months.  In  132  cases 
cpioted  by  Fagg  from  the  Registrar-Gi'ueral's  reports,  selected  because 
the  circumstances  regarding  the  incubation  were  accurately  known, 
the  shortest  incubation  was  eleven  days — a  case  in  which  a  child  was 
bitten  by  a  rabid  cat;  in  23  cases  it  was  under  a  month;  in  64,  be- 
tween one  and  two  months;  in  21,  between  two  and  three  months;  in 
24  cases  it  was  more  than  three  months.  The  average  incubation 
period  is  about  six  weeks,  but  the  length  is  undoubtedly  affected  by 
the  seat  and  severitv  of  the  wounds  and  the  atre  of  the  i)aticnt.     It  is 


438  BABIES;   UYDBOPUOBIA  ;   LYSSA. 

shorter,  as  a  rule,  wlicrc  the  wounds  are  on  exposed  parts  and  very  ex- 
tensive, and  is  shorter  in  children  tlian  in  adults.  As  has  been  stated, 
by  the  inoculation  of  rabbits  with  the  spinal  cord  of  others  dead  of 
rabies  Pasteur  was  able  to  reduce  the  incubation  period  to  about  seven 
days,  at  M'hieh  point  it  remained  constant.  This  virus  is  known  as  "  the 
tixe(l  virus  (cinis  fi.rt')  of  Pasteur." 

Symptoms  in  Man. — The  symjrtoms  of  rabies  in  man  present  a 
general  similarity  to  those  manifested  in  rabid  animals,  although  the 
most  striking  symptom,  that  from  which  the  disease  in  man  has  derived 
its  name,  is  peculiar  to  him.  The  disease  has  been  commonly  called 
"hydrophobia"  in  man  because  during  the  furious  stage  violent  spasms 
of  the  muscles  of  the  pharynx  and  the  elevators  of  the  larynx  and 
hyoid  bone  occur,  which  are  associated  with  intense  suffering.  When 
the  disease  is  fully  develojjed  these  paroxysms  are  often  brought  on  not 
only  by  attempts  at  swallowing,  but  even  by  the  sight  of  water  or  food, 
or,  in  fact,  by  any  peripheral  irritation.  Thus  the  patient,  although 
often  suffering  intensely  from  thirst,  is  tilled  with  such  terror  by  these 
spasms  that  he  cannot  be  induced  to  make  any  attemjit  to  take  fluid. 

The  disease  may  be  divided  into  three  stages — the  prodromal  stage, 
the  stage  of  excitement,  and  the  jiaralytic  stnge. 

Prodromal  Stage. — In  the  prodromal  stage  symptoms  may  or  may 
not  be  present.  In  many  cases  in  adults,  where  the  person  has  been 
bitten  by  a  dog  which  is  suspected  of  being  rabid,  there  develojjs 
gradually,  as  a  result  of  aiiprehension  and  fear  of  the  tlisease,  intense 
mental  depression.  The  fear  of  the  disease  acts  as  a  constant  nightmare, 
preventing  sleep,  disturbing  all  of  the  functions  of  the  body,  causing 
the  patient  to  relinquish  his  usual  occupation  and  often  to  resort  to 
alcohol  or  narcotics  to  relieve  the  mental  suffering  caused  by  fear.  In 
some  instances  the  })aticnt  may  become  almost  insane  from  terror  even 
when  there  is  no  good  reason  to  believe  the  animal  by  which  he  was 
bitten  was  rabid.  In  (ither  cases  the  flepression  dt)es  not  appear  until 
a  few  days  before  the  apj)earance  of  the  disease,  and  then  the  j)atient 
becomes  de]iressed  and  melancholy,  or  nervous,  restless,  sleepless,  and 
irritable.  There  may  be  pain  in  the  scar  of  the  original  bite ;  it  may 
become  swollen,  tender,  and  blue  ;  in  some  instances  it  is  said  that  the  scar 
opens  again  and  discharges  a  thin  watery  fluid,  or  a  papular  or  vesicular 
eruption  appears  round  it.  Occasionally  there  are  severe  shooting  pains, 
beginning  in  the  scar  and  extending  toward  the  trunk.  The  patient 
carefully  avoids  mentioning  the  circumstances  regarding  the  bite,  makes 
light  of  the  symptoms,  and  searches  for  diversion  away  from  home,  or 
it  may  be  seeks  solitude  at  lH>me.  There  may  be  even  now  some  in- 
crease in  the  sensibility  of  the  special  senses,  light  and  sound  ])roducing 
discomfort,  and  the  patient  may  complain  of  chilliness  while  the  ther- 
mometer shows  an  elevation  of  temperature  of  one  or  two  degrees.  After 
a  period  varying  from  a  few  hours  to  six  or  eight  days  the  symptoms 
become  more  defined  and  the  stage  of  excitement  begins. 

Stage  of  Excitement. — This  may  be  considered  as  really  the  beginning 
of  the  attack.  The  first  svmptoms  which  arouse  suspicion  as  to  the 
nature  of  the  disease  are  usually  some  pain  in  the  nuiscles  of  the  throat 
and  stiffness  or  difliculty  in  swallowing.  This  difticulty  in  swallowing 
rapidly  increases,  and  soon  any  attempts  at  deglutition  are  followed  by 


SYMPTOMS.  439 

violent  spasms  of  the  muscles  of  the  pharynx  and  hirvnx,  and  are 
(ifteii  associated  with  or  followed  by  spasms  of  the  respiratory  muscles. 
An  iutense  hypenesthesia  now  rapidly  develojis,  botii  of  the  nerves  of 
special  sense  and  of  general  sensibility ;  the  intensity  of  the  muscular 
spasms  increases  and  the  duration  of  the  interval  between  them  dimin- 
ishes, while  at  the  sauie  tiuie  they  extend,  iiivolvino-  not  only  the  nniscles 
(if  the  pharynx,  laryux,  and  respiration,  Init,  to  a  less  degree,  all  <)f  tlie 
voluntary  muscles  of  tlie  body.  At  first  these  paroxysms  are  l)rougiit 
on  only  by  attempts  to  swallow,  but  later  the  sight  of  fluids  or  food,  tiie 
sound  of  running  water,  a  ray  of  bright  ligiit,  a  slight  sound,  touching 
the  stu-facc  of  the  skin,  or  an  i/  afferent  impression  may  serve  to  excite  the 
])ar(ixvsms.  During  tlie  paroxysms  the  breathing  is  greatly  embarrassed 
and  painful,  and  is  interrupted  by  frequent  short  exjiiratory  efforts  ;  tiiere 
is  great  suffering  and  a  sense  of  impending  suffocation.  The  expression 
of  the  face  shows  most  intense  anxiety  and  apprehension.  The  patient, 
although  suffering  intensely  from  thirst,  refuses  to  attempt  to  drink,  or 
wlicn  the  litpiid  touches  his  lips  draws  back  in  terror  because  of  the 
recurrence  of  the  spasms.  Tiie  spasms  are  of  variable  duration,  lasting 
from  a  few  seconds  to  several  minutes,  and  in  rare  instances  death  has 
taken  place  during  a  paroxysm  from  aspiiyxia.  The  muscular  contrac- 
tions are  of  a  tetanic  character,  although  opistiiotonos  does  not  occur. 

At  first  the  mind  is  unclouded,  but  later  delirium  is  frequent,  and 
is  especially  marked  during  the  paroxysms  ;  at  such  times  "  tlie  patient 
may  make  violent  efforts  to  strike  or  injure  tlie  attendants  about  him, 
and  cries,  howls,  strikes  or  attempts  to  bite  others  or  himself,  until  lie 
sinks  back  exhausted,  and  remains  quiet  until  aroused  by  anotlier  par- 
oxvsm."  As  a  rule,  the  mind  is  clear  in  the  interval  between  the  par- 
oxysms. There  is  a  great  increase  in  the  secretion  of  saliva  :  it  is  thick 
and  tenacious,  and,  as  the  patient  cannot  swallow  it,  it  drivels  from  the 
mouth  or  he  violently  attempts  to  spit  it  out.  The  spasms  of  the  mus- 
cles of  the  throat  and  chest  are  often  associated  with  the  production  of 
a  peculiar  sound  which  the  imaginative  bystanders  transform  into  a  bark. 
It  is  this  that  is  described  when  the  patient  is  said  to  "  bark  like  a  dog." 

Pyrexia  is,  as  a  rule,  moderate,  although  the  temperature  may  go  to 
104°  or  105°  F.  Vomiting  is  common,  the  matter  rejected  being  usually 
of  a  greenish-brown  color.  There  may  be  incontinence  of  urine  and 
fieces.  The  urine  often  contains  albumin  in  large  quantity,  and  there 
may  be  casts  and  blood.     Sugar  is  occasionally  present. 

The  mental  delusions  are  frequently  associatcil  in  a  strange  way  with 
animals,  and  especially  dogs,  and  the  mental  excitement  and  fear  are 
stronglv  increased  bv  the  sight  of  a  dog.  In  children  the  mental  dis- 
turbance is  connnonly  less  marked,  and  it  bears  some  relation  apparently 
to  the  dc]iression'and  disturbance  caused  by  the  fear  of  the  disease  wliii'h 
has  preceded  its  advent.  The  stage  fif  excitement  lasts  a  varying  j)criod, 
from  a  few  hours  to  eight  or  ten  days.  As  a  rule,  however,  cases  termi- 
nate in  four  or  five  days. 

l'(ir(di/flc  Star/e. — A  few  hours  before  deatii  the  paroxysms  become 
less  severe  and  occur  at  longer  intervals.  The  ])atient  may  be  able  to 
swallow  and  take  I  food  without  difficulty;  tiie  mind  may  again  become 
clear,  but  the  pulse  is  rajiid  and  feeble,  and  the  disease  soon  terminates 
in  death.     Occasionally  there  is  more  or  less  complete  paralysis,  com- 


440  RABIES;  UYnRorilOBIA  ;   LYSSA. 

nienpiii^'  in  the  muscles  of  the  jaw  and  involving  partially  or  completely 
all  the  muscles  of  the  body  (paralytic  rabies),  and  rarely  coma  occurs. 
In  a  few  cases,  where  persons  have  received  very  extensive  bites  from 
wolves  on  exposed  parts,  the  disease  takes  early  the  form  of  paralytic 
rabies.  This  is  also  true  in  a  few  cases  whei'e  death  has  occurred  after 
inoculation  according  to  Pasteur's  method.  In  children  the  mental 
symptoms  are  usually  less  pronounced,  and  the  disease  terminates  earlier 
in  death. 

Prognosis. — Where  the  symptoms  of  true  rabies  have  once  devel- 
oped there  is  no  reason  to  look  for  recovery,  for,  although  tliere  have 
apparently  been  a  few  cases  which  have  recovered  without  treatment  or 
under  various  modes  of  treatment,  they  are  of  such  rare  occurrence  that 
they  give  little  reason  for  hope  in  any  individual  case.  Nevertheless, 
the  various  means  of  symptomatic  treatment  recommended  should  be 
employed  to  relieve  the  severity  of  tiie  paroxysms. 

The  percentage  of  eases  in  which  rallies  follows  the  bites  of  animals 
shown  to  be  rabid  or  supposed  to  be  rabid  is  variously  estimated — from 
5  to  60  or  80  per  cent.  The  bites  of  wolves  are  most  virulent,  and  next 
those  of  cats,  foxes,  and  dogs,  in  order.  Bites  on  exposed  parts  are  far 
more  likelv  to  l:)e  followed  by  the  disease  than  those  upon  covered  jiortions 
of  the  body,  and  punctured  or  greatly  lacerated  wounds  are  apparently 
the  most  dangerous.  Horsley  estimates  the  percentage  of  eases  of  hydro- 
phobia following  the  bites  of  animals  shown  to  be  rabid  as  about  16. 
Boul6,  however,  says  that  the  proportion  fixed  by  Hunter  (5  per  cent.) 
approaches  nearer  the  truth.  Following  bites  by  wolves  the  percentage 
of  cases  is  i\ir  higher,  varying  apparently  from  40  to  80  per  cent, 
of  those  l)itten. 

Diagnosis. — Great  suspicion  has  been  thro\\n  upon  the  diagnosis  in 
a  large  proportion  of  the  cases  of  reported  rabies,  and  much  has  been 
written  about  lyssophobia  or  pseudo-hydrophobia,  the  residt  of  fear. 
Numerous  cases  have  been  recorded  in  which  patients  apparently  sufler- 
ing  from  true  rabies  suddenly  recovered  when  the  animal  by  which  they 
were  bitten  appeared  before  them  well  or  when  they  were  convinced 
in  some  other  way  of  the  absence  of  rabies  in  it. 

In  a  well-marked  case  of  rabies  there  should  be  no  great  difficulty 
in  making  a  diagnosis.  No  doubt  a  part  of  the  difficulty  usually  ex- 
perienced is  due  to  the  extreme  rarity  of  the  disease,  few  physicians  in 
this  country  having  had  the  opjiortunity  of  seeing  a  single  case.  By 
far  the  most  characteristic  symptom  is  the  peculiar  respiratory  spasm 
caused  by  attempts  to  swallow  li(iuids,  and  where  this  is  present  increased 
significance  is  given  to  it  by  the  history  of  a  recent  bite.  Tliere  is  rarely 
some  difficulty  in  differentiating  rabies  from  tetanus  and  certain  forms 
of  organic  disease  of  the  lirain  and  insanity,  but  in  true  rabies  the  occur-, 
rence  of  the  respiratory  spasms  with  increasing  intensity  and  frequency, 
the  intense  hypera?sthesia,  and  the  existence  of  great  mental  disturbance 
— these  symptoms  followed  j)erhaps  l)y  paralysis — make  the  diagnosis 
clear.  The  absence  after  death  of  gross  lesions  sufficient  to  account  for 
the  condition  during  life  increases  the  ceitainty  of  the  diagnosis.  This 
mav  be  absolutely  confirmed  by  the  inoculation  of  rabbits  with  the  spinal 
cord  after  the  sul)dural  method  of  Pasteur. 

Pathological  Anatomy. — There  is  a  remarkable  variation   in  the 


PATHOLOGICAL  ANATOMl'.  441 

post-mortem  lesions  found  in  different  cases  of  rabies  as  it  occurs  in 
animals.  Not  infrequently  there  are  no  macroscopical  changes  found 
after  death  which  are  in  any  way  characteristic,  Init  in  those  cases  occur- 
ring in  dogs,  which  may  be  considered  most  tyi)ical,  we  find  that  the 
mucus  membrane  of  the  mouth  and  fauces  is  greatly  congested  and 
covei-ed  by  a  thick,  tenacious,  mucous  or  muco-purulent  secretion,  often 
mixed  with  dirt.  The  mucous  membrane  of  the  larynx,  trachea,  and 
bronchi  may  also  present  similar  appearances.  The  lungs  are  usually 
congested,  and  there  may  be  petechial  liemorrhages  into  the  pleura. 
The  heart  and  the  large  vessels  arising  from  it  are  filled  with  dark 
blood,  completely  fluid  or  containing  only  soft  dark  clots.  The  most 
characteristic  changes  are  found  in  the  stomach.  This  is  usually  filled 
with  all  sorts  of  foreign  bodies  if  the  animal  has  been  free,  or,  if  it  has 
been  confined,  with  such  as  are  within  reach.  In  animals  which  have 
been  running  loose,  hay  and  straw,  pieces  of  w"ood,  coal,  leather,  })ortions 
of  cloths,  stones,  sand,  earth,  and  ficces  are  indiscriminately  mixed 
together,  and  not  infrequently  similar  contents  are  found  in  the  small 
intestines.  The  large  intestine  is  often  empty.  The  mucous  membrane 
of  the  stomach  and  of  the  small  intestines,  particularly  of  the  stomach, 
.shows  clianges  quite  similar  to  those  found  in  the  throat  and  larynx,  but 
in  a  higlier  degree.  The  mucous  memlirane  of  the  stomat-li  is  intensely 
swollen,  hvpeneiiiic,  filled  with  extravasations  of  blood,  and  may  be  the 
seat  of  nuiuerou-;  ciosions.  It  is  covered  with  a  thick,  tenacious  mucus. 
i'lic  jiif;  -linal  nuicous  membrane  presents  the  same  appearance  in  a  less 
(iegree.  The  kidneys  are  commonly  swollen,  of  diminished  consistence, 
and  show  marked  hy])era3mia.  The  bladder  is  emjity,  or  at  most  C(jntains 
a  small  (piantity  of  cloudy,  and  it  may  be  albuminous,  urine ;  occasion- 
ally the  urine  contains  blood.  The  mucous  membrane  of  the  Itladder 
is  also  swollen,  and  sometimes  shows  petechial  hemorrhages  into  its  sub- 
stance. In  the  central  nervous  system  there  are  no  characteristic  changes 
visible  to  the  naked  eye.  As  a  rule,  there  is  marked  hyperemia  of  the 
spinal  cord  and  the  medulla  and  their  meninges,  and  occasionally  minute 
hemorrhages  may  be  found  in  tiie  floor  of  the  fourth  ventricle.  The 
brain  and  its  meninges  may  also  present  the  same  appearances,  but  these 
are  not  constant  or  eharacterlstie  enouo-h  to  have  great  sionificance.  Not 
infrequently,  especially  in  those  cases  which  terminate  rapidly,  there  may 
be  few  or  no  lesions  in  any  way  characteristic.  The  stomach  may  be 
empty,  and  at  most  the  mucous  membrane  of  the  respiratory  and  alimen- 
tary tracts  aj)]3ears  swollen  and  somewhat  hy]iera?mic.  The  intestines 
may  contain  no  normal  jn'oducts  of  stomach  digestion,  and  the  contents 
show  littl(>  or  no  bile-staining.  There  may  be  nothing  else  abnormal 
found  in  the  thoracic  or  abdominal  viscera.  The  brain  and  spinal  cord 
may  present  no  changes. 

In  man  the  post-mortem  changes  apparent  to  the  naked  eye  are 
essentially  those  of  an  acute  infectious  disease,  with  possibly  more 
marked  congestion  of  the  mucous  membrane  of  the  alimentary  and 
respiratory  tracts,  and  more  marked  hv]5er;emia  of  the  lirain  and  spinal 
cord  and  their  meninges,  than  is  usually  present  in  other  types  of 
infectious  disease.  It  is,  however,  rather  the  absence  of  characteristic 
changes  M'hich  is  significant  in  post-mortems  on  suspicious  cases  than  the 
presence  of  any  definite  gross  lesions. 


442  RABIES;   HYDROPHOBIA;   LYSSA. 

The  microscopical  finding's  in  tlic  spinal  cord  and  medulla  are  more 
characteristic,  and  assist  in  tlie  diagnosis  of  doubtful  cases.  Sections 
should  lie  made  through  the  hulh  or  cervical  division  of  the  cord.  In 
these  regions  there  is  found  microscopically  marked  hypersemia,  with 
perivascular  foci  of  embryonic  cell  infiltration,  and  little  nodules  of  em- 
bryonic cells  surrounding  degenerated  or  proliferating  nerve-cells.  If 
these  nodules  are  not  found,  probably  the  case  is  not  rallies;  if  found, 
probably  the  case  is  rabies.  The  nodules  arc  less  conspicuous  in  animals 
killed  in  the  first  stages  of  rabies  than  in  those  which  have  succumbed  to 
the  disease. 

We  ma}^  also  find  (1)  hypenemia  and  acute  (jedema  of  the  meninges, 
with  small  hemorrhages  around  some  of  the  vessels;  (2)  proliferation  of 
the  epithelium  of  the  central  cerebro-spinal  canal,  hemorrhages  in  the 
gray  matter,  and  obliteration  or  throndjosis  of  some  of  the  small  vessels 
by  a  hyaline  pigmented  substance,  by  leucocytes,  or  by  hyaline  degenera- 
tion ;  (o)  little  foci  of  degeneration  in  the  gray  matter.  These  foci  are 
often  visible  to  the  naked  eye. 

The  lesions  of  the  nerve-cells  in  special  regions  are  characteristic. 
They  consist  in  the  signs  of  proliferation,  and  even  in  the  presence  of 
several  small  cells  in  the  pkjce  of  a  large  one,  or  in  a  uniform  degenera- 
tion. jMonomiclear,  and  rarely  i)olynuclear,  cells  of  lymphatic  origin 
invade  the  protoplasm  of  the  cell  and  fill  the  pericellular  lymphatic 
spaces,  dilating  them  to  form  nodes  (Roux). 

When  a  human  l)eing  has  been  l)ittcn  by  an  animal  which  has  been 
afterward  killed,  it  is  advisable,  if  possilile,  to  make  a  diagnosis  from  the 
autoj)sy  and  the  microscopical  examination  of  the  medulla  antl  cord,  so 
that  ])roper  advice  may  be  gi\'en  regarding  the  necessity  of  treatment. 

Prophylaxis. — The  importance  of  prevention  in  any  disease  is  pro- 
portionate tx)  its  frequency  and  mortality,  and  while  in  hydrophobia, 
because  of  its  rarity  in  man,  the  prevention  is  seemingly  of  less  import- 
ance, yet,  because  of  its  almost  universally  fatal  ending,  pro})hylaxis 
becomes  of  great  moment.  As  there  is  positive  proof  that  the  disease 
is  the  result  only  of  infection,  and,  in  the  vast  majority  of  cases,  of 
infection  through  the  bite  of  a  rabid  animal,  the  prevention  of  hydro- 
phobia in  man  resolves  itself  into  the  jirevention  of  rabies  in  animals ; 
and  experience  has  shown  without  question  that  the  disease  in  animals — 
in  dogs — can  be  completely  stani]ied  out  by  the  eificient  enfn-cement  of 
laws  rec[uiring  the  registration  and  muzzling  of  dogs.  In  Prussia  the 
disease  has  become  practically  extinct  through  such  means ;  in  Holland 
the  same  is  true  ;  and,  in  flict,  in  every  country,  city,  or  district  in  which 
laws  requiring  the  muzzling  and  registering  of  dogs  have  been  efficiently 
enforced  the  disease  has  promptly  and  completely  disappeared. 

Treatment. — Preventive. — In  1885,  after  a  long  series  of  exper- 
imental investigations  on  animals,  Pasteur  announced  the  discovery  of 
a  method  for  the  jirevention  of  rabies  in  those  who  had  been  bitten  by 
rabid  dogs,  and  in  July  of  that  year  he  first  apjilied  the  treatment  to  a 
human  being  in  the  case  of  a  boy  named  Joseph  jNIeister. 

The  Pasteur  system  of  treatment  dejiends  upon  the  following  obser- 
vations :  (1)  the  rabic  virus  is  especially  present  in  the  medulla  and 
spinal  cord  of  animals  dead  of  rallies;  (2)  by  the  successive  subdural 
inoculation  of  rabbits  with  an  enudsion  prepared  from  the  spinal  cord 


TREATMENT.  443 

of  an  animal  dead  of  rabies  the  incubation  period  is  gradually  shortened 
until  it  tinally  becomes  fixed  at  seven  or  eight  days ;  (3)  spinal  cords 
removed  from  animals  that  have  died  after  such  inoculations,  if  dried  in 
sterilized  jars  over  potash  at  a  temperature  of  about  73°  F.,  gradually 
lose  their  virulence,  and  at  the  end  of  fourteen  days  are  innocuous  when 
used  for  the  inoculation  of  animals  or  men  ;  (4)  if  an  animal  or  man  is 
inoculated  on  succeeding  days  with  the  spinal  cords  which  have  been 
dried  for  successively  sliorter  periods,  the  individuals  are  gradually 
rendered  insusceptil)lc  to  tiie  more  virulent  cords  l)y  tliosc  of  less  viru- 
lence which  were  previously  used  ;  (5)  if  these  inoculations  are  made 
after  an  individual  has  been  bitten  by  a  rabid  dog,  protection  may  be 
still  conferred  in  the  majority  of  instances,  providing  too  much  time  has 
not  elapsed  between  the  bite  and  the  beginning  of  the  inoculations. 

The  fornuda  for  the  treatment  t)f  ordinary  l)ites  (not  those  about  the 
head)  is  given  below  : 


1st  day,  cord  of 

12 


I  14  diivs  in  dose  of  3  cm.  of  emulsion. 
I  1.3     "■ 


2d      "  "       Wi 

3d      •' 


4th 

5tli 

6tli 

7  th 

8th 

9th 

10th 

11th 

12th 

13th 

14th 

15th 


(10 
1    9 

(    S 


1    '     ' 
(    6     " 

2  cm. 

l    6     " 

" 

5     " 

u 

5     " 

u 

4-  " 

" 

3     " 

1  cm. 

5     " 

2  cm. 

5    " 

" 

4    " 

« 

4    " 

(( 

3     " 

" 

3     " 

u 

For  bites  about  the  head  and    face  a  somewhat  intensified  method  is 
emj>loyed. 

From  1886  to  1891,  inclusive,  nearly  10,000  persons  were  inoculated 
in  the  Pasteur  Institute,  with  the  result  as  shown  below  : 


Year. 

Persons  treated. 

Deaths. 

Percentage  of  mortality. 

1886 

2671 

25 

.94 

1887 

1770 

13 

.73 

1888 

1622 

9 

.55 

1889 

1830 

7 

.39 

1890 

1550 

5 

.32 

1891 

1559 

4 

.25 

In  these  statistics,  in  the  later  years  the  deaths  have  been  excluded  when 
they  occurred  within  fifteen  days  of  the  la.st  inoculation,  as  it  was  then 
assumed  that  the  virus  intniduccd  by  the  bite  was  acting  on  the  central 
nervous  system  before  imnumity  had  been  conferred  by  the  inoculations. 
There  were  five  cases  of  this  kind  in  tlic  year  1891,  which  have  been 
excluded  from  these  statistit-s. 

The  cases  treated  have  been  divided  into  three  classes :  (a)  persons 
bitten  by  dogs  in  which  the  existence  of  rabies  was  proved  by  inf)eula- 


444  RABIES;   IIYDROPnOBTA  ;   LYSSA. 

tion  or  by  the  sul)s('([utMit  iiccurrciicc  of"  raljics  in  iinotlicr  aniiiuil  ;  (b) 
persons  bitten  by  animals  in  whicli  the  existence  ot"  rabies  was  confirmed 
by  a  veterinary  surgeon  ;  (c)  persons  bitten  by  animals  suspected  of  having 
rabies.  Roux  refers  to  710  cases  treated  in  Class  a,  where  the  bites  were 
on  exposed  parts  about  the  head,  in  which  only  24  died — a  mortality  of 
3. .38  per  cent.  He  declares  that  the  mortality  in  this  class  of  cases  with- 
out treatment  would  be  about  SO  per  cent.  It  is  particularly  in  those 
cases  in  wliich  the  bites  are  upon  exposed  parts  that  the  mortality  is 
greatest. 

Whether  we  accept  as  final  oi-  not  the  statistics  of  the  Pasteur  Insti- 
tute as  t(  >  the  efficiency  of  the  treatment,  yet  it  may  lie  safely  concluded  from 
the  results  of  the  Pasteur  inoculations  that  tiicre  is  comjtarativclv  little 
danger  from  the  inoculation  itself,  and  that  the  mortality  in  ])ersons 
after  treatment  bitten  In'  dogs  knoMn  or  suspected  to  be  rabid  is  far 
lower  than  it  has  ever  been  before. 

Treatment  of  Bites. — In  the  immediate  treatment  of  bites  from  ani- 
mals supposed  to  be  rabid  the  main  object  is  the  elimination  of  the 
poison.  If  the  \vound  is  in  an  extremity,  where  the  circulation  can  be 
controlled,  a  ligature  should  be  immediately  applied,  bleeding  promoted, 
the  ])art  thoroughly  soaked  in  an  antiseptic  solution,  or,  if  it  is  a  punc- 
tured wound,  the  wound  sucked  and  the  mouth  afterward  repeatedly 
washed  out  with  a  disinfecting  solution  ;  intermittent  squeezing  and 
wringing  of  the  ]iart  while  it  is  soaked  in  warm  water  is  an  excellent 
method  for  jiromoting  bleeding  and  eliminating  the  poison.  The 
M'ound  may  be  o|)ened  to  its  depth  and  cauterized  witii  actual  cautery 
or  with  mineral  acids  or  nitrate  of  silver,  or  the  wound  may  be  excised. 
Tlie  more  quickly  and  completely  the  poison  is  eliminated  after  the  bite, 
the  less  is  the  danger  from  the  bite.  However,  there  is  good  reason  to 
believe  that  even  if  the  treatment  of  the  wound  is  not  begun  until  some 
hours  after  the  wound  was  inflicted,  yet  a  considerable  measure  of  pro- 
tection may  l)e  thus  granted,  for  it  seems  probable  that  the  poison  may 
be  localized  for  a  considerable  period  at  the  point  of  its  introduction ; 
hence  in  any  case  where  it  is  thought  possible  that  the  wound  was 
inflicted  by  a  rabid  animal  it  should  be  thoroughly  washed  and  cauter- 
ized even  if  a  considerable  period  has  elapseil  since  the  injury. 

Therapeutic.  Treatment. — During  the  incubation  period  the  psychical 
treatment  is  of  special  importance.  Great  care  should  be  taken  to  dis- 
tract the  patient's  attention  from  the  subject  of  the  bite,  and  nothing 
should  be  said  or  done  which  directs  attention  to  it.  The  other  meas- 
ures during  the  ])criod  of  incubation  pertain  simjily  to  general  hygiene. 
After  symptoms  have  appeared  there  is  little  reason  to  anticipate  anything 
but  a  fatal  rcsidt,  and  the  treatment  should  lie  purely  symptomatic,  and 
consist  in  the  use  of  spinal  and  cerebral  sedatives  and  antisjiasmodics. 

Some  observations  have  recently  been  reported — jiartieularly  by 
Chantemesse,  Tizzoni,  Centanni,  and  Babes — M'hich  offer  bright  hof)e 
in  the  early  future  of  the  perfection  of  a  specific  means  of  treatment 
of  hydrophobia  through  the  use  of  an  antitoxine  separated  from  the 
blood  of  animals  which  have  been  rendered  artificially  imnume  to 
rabies.  The  observations  thus  far  made,  however,  arc  as  yet  too  incom- 
plete to  render  the  measures  available  for  the  practical  treatment  of 
hydrophobia. 


GUNSHOT  WOUNDS. 


By  p.  S.  CONNER,  M.  D. 


No  class  of  injuries  has  more  occuijicd  tlie  attention  of  surgeons  and 
surgical  writers  than  tliose  jjroduced  l)y  gunshot,  and  from  the  study 
of  no  other  class  has  greater  benefit  accrued  to  the  art  of  surgery  in 
general.  But  the  great  changes  that  in  very  recent  times  have  been 
made  in  weapons,  in  missiles,  and,  especially,  in  the  treatment  of  all 
wounds,  necessitates  reconsideration  of  not  a  few  questions  connected 
with  the  nature,  tiie  care,  and  the  results  of  these  wounds ;  respecting 
which  mucli  that  has  been  written  is  now  of  historic  rather  than 
practical  value. 

As  met  with  in  civil  life,  gunshot  wounds  are  commonly  produced 
by  pistol  halls  or  small  siiot ;  in  military  service,  by  rifle  bullets,  by 
large  solid  shot  or  shell,  or  by  balls  tin-own  out  from  case  or  canister 
shot.  A  small  proportion  of  the  injuries  are  caused  by  caps,  by  por- 
tions of  a  gun  whicli  has  burst,  or  by  a  splinter  of  wood  or  a  piece  of 
stone  or  metal  set  in  motion  by  impact  of  a  shot. 

Missiles. 

Small  shot  vary  greatly  in  size  and  weigiit,  the  extremes  being  "  fine 
dust,"  the  particles  of  which  weigh  less  than  2^,5-  gr.  each,  and  buckshot 
of  .44  in.  diameter  and  153  grs.  weight.  Pistol  balls  also  are  of  various 
shapes,  sizes,  and  weights,  ranging  from  a  calibre  of  .22  to  .45  of  an 
inch,  and  a  weight  of  from  25  to  250  grs.,  all  more  or  less  conical,  made 


Country. 


Austria  . 
Belgium  . 
Denmark 
England  . 
France 


Type. 


Mannlicher  .  . 
Mauser  .... 
Krag-Jorgensen 
Lee-Metford  .  . 
Lebel 


Berlhier  .... 
Germany iMannlicher  .  . 

Italy jCarcano  .  . 

Japan Murata 

Portugal Kropatschek .  . 

Russia Mouzin    .   . 

Spain Mauser 

Switzerland Sclimidt  .... 

United  States,  new  .  Krag-Jorgensen 
United  States,  old  .  .  Springlield .  .  . 


.315 

.301 
.315 
.303 
.315 

.301 
.311 

.256 
.315 
.315 
.300 
.295 
.295 
.300 
.450 


.244 
.217 
.235 
.215 
.231 

.231 
.227 

.155 
.238 
.245 
.211 
.245 
.211 
.220 
.500 


to  2 

c5  to 


42 
38 
34 
30 
43 

43 
42 

32 
.S6 

35  (bl 
35 
38 


aek) 


70  (black) 


Bullet-covering. 


Steel  

'German  silver 

Copper 

Nickel  and  copper .... 

Mailleohort  (alloy  of  cop- 
per, nickel,  and  zinc)   . 

Mnillrchort 

strcl  {plated  with  aUoy  of 
cnp]n.-r  :ind  nickel)    .  . 

Muilk'chort 

Copper 

Copper 

Mailleehort 

Maillechort 

Copper  or  steel 

German  silver 


1968 
1980 
1950 
2000 

2073 
2971 

2034 
2329 
1857 
1984 
2000 
2285 
1969 
2000 
1300 


445 


446 


GUNSHOT   WOUNDS. 


a 


^^ 


o"  lO  oi 


00 


.5    bt'  5  p, 

a  III 


Qj  a;  oj  ?- 

(-<     (H     ^ 

£.'S£a> 
iC  oo  ^> 


:>    .-'(NM 


M4     ^ 

either  of  .soft  lead  or  of  lead  hardened  l\y  admixture  of  tin  from  1  to 
40  to  1  to  20  parts.  Until  recently  army  bullets  were  of  large  size, 
those  employed  in  our  late  war  varying  in  calibre  from  .50  to  .71  of  an 


MISSILES.  447 

incli,  and  in  weight  from  400  to  760  grs.,  and  even  to-day  the  service 
bullet  of  our  army  has  a  diameter  of  .45  in.  and  a  weight  of  500  grs. 
Yerv  soon,  however,  in  common  with  other  nations,  we  will  have  a 
iitandard  ritle  of  small  calibre  and  a  l)ullet  of  tlie  modern  type,  long, 
slender,  cvlin<lro-ogival,  of  calibre  of  about  .30  in.  ]\Iadc  of  hardened 
lead  (lead  and  antimony),  the  new  bullet  is  covered  witli  a  thin  jacket 
of  steel,  coi)j)er,  nickel,  or  au  alloy  of  these  metals,  with  or  without  zinc 
addition.'  To  further  reduce  its  weight,  it  has  been  proposed  to  tunnel 
it  from  end  to  end,  making  of  it  a  sort  of  punch.  The  weight  of  the 
bullet  issued  to  the  Euroj)ean  armies  varies  from  155  to  245  grs.,  and 
its  lengtli  from  ■^  to  4  calibres.  That  the  desired  momentum  may  be 
had,  lessened  weight  is  compensated  for  by  increased  velocity,  'iOOO  feet 
or  over  per  second  (2971  feet  with  the  Berthier  carbine  of  the  French), 
instead  of  1300,  as  is  the  case  when  black  powder  and  the  Springfield 
rifle  are  used.  Because  of  its  swiftness  of  fligiit  and  the  increased  rota- 
tion due  to  the  changed  rifling  of  the  piece,  tlie  trajectory  of  one  of 
these  bullets  is  very  flat,  its  range  very  long,  and  its  penetrating  ])ower 
very  great."  It  is  little  likely  to  be  deformed,  and,  especially  when 
steel-mantled,  any  deformity  produced  is  usually  but  a  slight  flattening 
of  the  apex.  It  almost  never  breaks  up,  and  sjilitting  or  stripping  ofl' 
of  the  jacket  in  part  or  whole  is  rare  ;  particularly  so  when  of  steel, 
copper  vielding  much  more  readily.  Boring  rather  than  crushing,  in 
vcrv  exceptional  cases  lodging,  and  then  t>nly  when  near  the  end  of 
a  long  flight  or  after  having  previously  encountered  much  resistance, 
these  new  bullets  may  be  expected  to  produce  lesions  in  many  respects 
different  from  tho.se  met  with  heretofore.  Experimentally,  much  has 
been  determined,  and  the  limited  experience  that  has  been  had  in  recent 
wars  in  Africa,  South  America,  and  Asia  conflrms  the  results  of  the 
experiments  made  by  European  and  American  surgeons'  upon  animals 
and  human  cadavers. 

Gexerai.  Consider.\tions. — With  few  exceptions,  gunshot  wounds 
are  of  the  lacerated  and  contused  order.  According  to  direction  and 
momentum,  the  shot  may  graze  or  bruise  the  surface  of  the  body,  may 
enter  and  lodge,  or  pass  through  and  out — in  other  words,  contuse,  pen- 
etrate, or  perforate.  In  proportion  as  tlie  bullets  have  been  made  harder 
and  their  velocity  increased  the  likelihood  of  their  lodging  in  the  body 
has  been  lessened,  so  tiiat  even  in  the  pistol  wounds  of  civil  life  perfora- 
tion is  of  frequent  occurrence,  or  the  bullet  is  often  found  to  be  lodged  just 
under  the  skin,  the  elasticity  of  which  has  prevented  its  passing  through. 

Leaving  out  of  consideration  the  injuries  inflicted  within  tlie  "  zone 
of  explosive  action  "  and  aft'ecting  bone,  tliat  witli  few  exccjitions  have 
up  to  the  present  time  been  only  experiiiK'ntaliy  produced,  and  in  wliich 
the  exit  wounds  are  6f  very  large  size,  the  old-time  great  difference  in  the 
size  of  the  wounds  of  entrance  and  exit  no  longer  exists,  even  when  the 
ball  has  passed  through  bone.  The  diameter  of  each  wound  is  aliout 
that  of  the  Itullet ;  it  may  be  a  little  smaller,  it  may  be  a  little  larger. 

'  See  table  at  font  of  pajje  445. 

-  The  degree  of  (jenetratian  as  rompared  with  that  of  the  old  bullet  is  shown  by  the 
accompanving  figure  (Fig.  14 1,  taken  from  Asst.  Snrg.  La  Garde's  report  to  the  Surgeon- 
General  of  our  army. 

"  Delorme,  Chavasse,  Chauvel,  Nimier,  Koclier,  Bruns,  Busch,  Keger,  Morosow, 
Tauber,  Pawlow,  Ilabart,  Horslev,  La  Garde,  and  uthere. 


448 


G  VNSHO  T   WO  UNDS. 


The  skill  about  tlu' wotiiid  of  entrance  is  often  somewhat  depressed,  about 
the  wound  of  exit  everted.  Both  wounds  may  appear  as  if  made  with  a 
punch  ;  that  of  exit  is  very  often  stellate,  ti-iangular,  or  even  linear.  A 
narrow  dark-colored  ring  surrounds  the  opening,  especially  that  of  entrance, 
due  not  to  the  heat  of  tlie  shot,  but  to  the  extravasation  of  blood  from 
vessels  of  the  superticial  fascia,  which  because  of  its  lessened  elasticity  is 
somewhat  stripped  off  tlie  skin.  As  far  liack  as  the  time  of  Pare  and 
Maggius  it  was  demonstrated  that  the  shot  was  not  hot  enough  to  ignite 
gunpowder  in  sacks  into  which  it  had  been  fired,  and  could  not  thei'efore 
burn  the  edges  of  a  wound.  W^hen  the  wound  has  been  inflicted  at  very 
close  range  powder-staining  of  tlie  parts  has  been  often  observed;  with 
the  use  of  metallic  cartridges  and  the  improvements  in  powder  manufac- 
ture, securing  more  tiioroiigli  combustion,  such  staining  is  becoming  less 
and  less  frequent.  The  distance  at  which  the  marking  may  occur  is  by 
no  means  absolutely  determined  (as  reported,  varying  between  2  and  10 
feet),  and  cannot  be  definitely  stated  because  of  the  variations  in  the 
quality  of  powder  used.  In  some  experiments  made  by  Professors  Frost 
and  JJartlett  of  the  I)artmoutli  jMedical  College  three  years  ago  with 
Winchester-rifle  cartridges  cal.  .44,  fii'ed  from  a  revolver,  it  was  found 
that  at  3  feet  distance  heavy  wrapping  paper  was  "  perforated  with  clean 


Fig.  15. 


;Miiltipk' shot-wounds  of  anas  nnd  Imck.    The  opcMiinp  <ivit  the  spine  was  produced  by  pressure, 
not  by  the  bull.    (Ciise  in  Cincinnati  Huspitul,  ISM.) 

sharp  angular  holes  in  great  number.  These  holes,  though  less  in  num- 
ber at  the  circumference,  extended  H  feet  from  the  bullet-hole  or  covered 
a  circle  3  feet  in  diameter,  the  bullet-hole  being  in  the  centre." 


MISSILES. 


449 


At  times  the  course  of  the  bullet  carries  it  in  and  out  and  in  and  out, 
giving  rise  to  two,  four,  six,  or  more  wounds  (see  Fig.  15),  or,  if  lodge- 
ment finally  takes  place,  three,  five,  etc. 

Occasionally  it  may  Ijecome  a  question  A\hcther  two  existing  wounds 

are  those  of  entrance  and  exit  of  a  single  ball  or  of  entrance  of  t\vo 

balls,  but  the  answer  will  likely  be  found  in  the  position  of  the  openings 

relative  to  the  line  of  fire.     At  times,  because  of  splitting  of  the  bullet,' 

Fig.  16.  Fig.  17. 


% 


E.xtfi'iur  view  (A.  M.  M.,  Sect.  1,  Spec.  2121).  Interior  view. 

there  may  be  two  wounds  of  exit — a  condition  which  is  much  less  likely 
of  occurrence  now  tiian  formerly,  since  the  pistol  ball  is  so  often  of 
hardened  lead,  and  the  mantled  riHc  bullet  will  maintain  its  integrity  no 
matter  what  it  strikes  in  the  biidy. 

In  its  passage  through  any  tissue  the  shot  commonly  destroys  out- 
right tiiat  which  is  in  front  of  it,  and  to  a  variable  distance  devitalizes 
that  which  surrounds  its  track.  The  greater  the  elasticity  of  the  tissue, 
the  less  the  direct  destruction ;  e.  r/.  the  skin  may  be  only  split,  or  the 
cranium  may  be  pierced  anil  yet  but  a  crack  be  observed,  or  even  this 
not  be  discovered.  The  gross  anatomical  structure  of  the  part  may 
greatly  limit  the  destructive  action  of  the  bullet,  as  in  a  muscle  longi- 
tudinally traversed,  in  which  the  track  may  be  traced  with  great  difficulty 
or  not  at  all.  The  area  of  devitalization  varies  with  the  tissue,  the  size, 
shape,  and  velocity  of  the  l)all,  and  the  period  of  flight  in  which  impact 
occurs.  Stated  in  a  general  way,  it  is  decidedly  less  than  in  former 
times,  the  bullets  being  smaller,  less  deformed,  and  having  a  quicker, 
steadier  flight.  In  the  experiments  that  have  been  made  it  has  been 
noticed  that  in  the  early  and  late  portions  of  their  flight — /.  e.  within 
300  to  500  yards  and  beyond  1800  or  2000  yards — the  new  army  bullets 
destroy  as  nmch  as,  or  more  than,  the  Imllets  jn-eviously  used,  but  in  the 
intermediate  distances  the  damage  done  is  markedly  less.  In  ]>art,  at 
least,  an  explanation  of  the  observed  differences  maybe  found  in  the  lat- 
eral swing  of  the  ball  before  its  axial  rotation  is  thorouglily  established 
and  after  its  velocity  becomes  greatly  diminished,  as  in  the  early  and  late 
wabbling  of  a  top,  which  spins  steadily  during  the  middle  period  of  its 
rotation.  So  great  is  the  destruction  effected  in  the  shorter  ranges  that 
these  latter  constitute  a  "zone  of  explosive  action,"  tlie  middle  distances 
belonging  to  the  "  zone  of  penetration,"  beyond  which,  near  the  end 
of  the  missile's  flight,  is  the  "zone  of  contusion."  The  most  inten.se 
explosive  action  is  seen  in  wounds  of  tissues  rich  in  fluid  contained 

'  As  illustrating  the  splitting  of  a  bullet,  Figs.  16  and  17  are  given  of  specimen  in  the 
Array  Medical  Museum  at  Washington. 
Vol.  I.— 2S) 


450  GUNSHOT   WOUXDS. 

within  comparatively  iinyieklin^  walls,  as  in  lesions  of  the  brain,  though 
saeh  hydrostatic — or,  better,  hydrodyiianiie — pressure  may  be  strongly 
exerted  ujjou  the  solid  viscera  of  the  abdomen,  and  even  upon  the  hollow 
viscera  wlien  full  (if  fluid  or  semi-fluid  contents. 

The  course  of  the  ball  may  be  expected  to  be  direct.  Deflection  of 
the  new  army  bullet  will  probably  never  occur,  and  as  the  pistol  ball  is 
made  harder  and  the  (juality  of  the  powder  improved,  it  will  become 
more  and  more  rare  to  find  in  civil  life  a  change  in  the  line  of  direction. 
Even  with  tiie  soft-lead  conical  ball  such  change  is  not  very  likely  to 
happen,  and  in  many  cases  in  which  it  has  l)een  believed  to  occur  the 
course  has  been  a  straight  one,  the  body  as  it  was  struck  having  been 
put  into  such  position  as  to  give  an  appearance  of  deflection. 

Much  less  frequently  than  before  will  blood-vessels  in  the  track  of 
the  bullet  escape  injury  ;  but  the  smaller  .size  of  the  missile  and  the 
diminished  cross-section  of  the  ai'ea  of  devitalization  must  lessen  the 
number  of  vessels  damaged.  Nerve-trunks  are  more  likely  to  be 
uninjured  than  the  vessels. 

As  a  rule  having  comparatively  few  exceptions,  the  damage  done  by 
a  bullet  is  produced  in  its  passage,  and  when  it  lias  come  to  a  state  of 
rest  it  commonly  ceases  to  do  harm,  at  least  wlien  the  lodgement  is  in 
the  soft  parts.  Though  when  so  located  it  sometimes  changes  position 
because  of  weight  and  muscular  action,  it  ordinarily  does  not,  but  quickly 
becomes  encapsulated  and  fixeil.  In  one  of  the  softer  viscera,  especially 
the  brain,  it  may  produce  serious  pressure-symptoms  either  where  pri- 
mai'ilv  ])laced  or  in  some  more  de])endent  position  to  which  it  has  in 
time  gravitated  ;  resting  against  the  wall  of  a  hollow  viscus,  it  may 
afterward  by  ulceration  reach  its  interior. 

That  lodgement  has  occurred  may  be  inferred  with  almost  absolute 
certainty  when  there  is  present  a  wound  of  entrance  only.  The  old- 
time  round  ball,  even  of  considerable  size,  sometimes  carried  in  a  piece 
of  clothing,  in  which  it  rested  as  a  finger  in  a  glove,  and  with  the  with- 
drawal of  such  pocket  the  shot  was  pulled  out  ;  but  the  bullet  of  to-day 
is  excessi\ely  unlikely  to  behave  in  such  manner.  In  a  few  cases  on 
rectnxl  the  shot  has  passed  out  of  a  natural  opening,  as  in  other  cases  it 
has  entered  through  such. 

Determination  of  the  position  of  a  bullet  may  be  made  by  palpation 
of  the  injured  area  or  of  the  surface  toward  which  tlie  shot  was  tending, 
bv  digital  exploration  of  the  wound,  by  jjrobing,  and  by  the  use  of  an 
electrical  apparatus.  Very  often  the  desired  information  will  be  gained 
by  palpation,  and  in  the  wounds  of  the  external  soft  parts  met  with  in 
civil  life  a  bullet  that  cannot  be  thus  located  had  better  be  let  alone 
rather  than  sought  for  instrumentally.  "When  the  track  of  the  ball  is  large 
enough  to  permit  of  the  use  of  the  finger,  this  best  of  instruments  should 
be  employed,  as  by  it  can  be  well  ascertained  the  nature  and  extent  of 
the  damage  done.  By  it  alone  can  the  ]iresence  of  pieces  of  clothing 
be  determined.  Enlargement  with  the  knife  of  the  wound  of  entrance 
and  of  the  track,  of  which  in  the  jKist  there  have  been  many  strong 
advocates,  is  certainly  not  required  in  cases  of  pistol-ball  injury,  and 
with  the  new  military  rifle  the  wounds  in  very  large  proportion  will  be 
those  of  perforation,  not  penetration.  If  in  any  given  case  there  is  good 
reason  for  believing  that  a  piece  (not  shreds)  of  clothing  has  been  carried 


MISSILES. 


451 


in  with  the  l)all,  careful  search  for  it  slioiild  he  made  with  the  fin<>'er, 
with  or  without  enhirgement  of  the  wouikI  according  to  circumstances. 
By  no  probing  with  a  metallic  instrument  can  the  presence  of  cloth  be 
■determined,  and  if  left  in  place  it  is  certain  to  be  a  source  of  infection. 
Fortunately,  the  modern  conical  bullet  with  its  great  velocity  compara- 
tively rarely  carries  in  with  it  this  septic  complicating  foreign  Ixxly. 

If  a  probe  is  to  be  nsetl,  it  should  be  bulbous-ended  and  of  a  diam- 
eter but  little  less  than  that  of  the  bullet,  is  best  made  of  aluminum, 
because  of  the  lightness  of  this  metal,  and  never  should  be  employed 
without  precedent  thorough  cleansing.  Under  no  circumstances  should 
a  gunshot  woun<l  be  touclied  with  unclean  finger  or  unclean  probe  ;  far 
better  that  it  sliould  liave  nA  treatment  at  all.  The  ])orcelain-tij)ped 
probe  with  which  Xclaton's  name  is  so  commonly  associated,  that  rubbed 
against  the  bullet  takes  a  lead  stain,  has  often  proved  of  value,  but  not  in- 
frequently has  failed  of  accomplishing  its  purpose,  either  the  surface  of 
the  bullet  not  being  exposed  or  the  pressure  upon  it  not  suificiently  great. 

Of  electrical  devices  to  determine  the  presence  and  place  of  a  ball, 
not  a  few  have  been  ])resented  to  tlie  surgical  world,  some  indicating  the 
presence  of  the  missile  by  deflection  of  a  galvanometer,  others  l)y  sound. 
Of  these  latter  the  best  is  the  telephonic  probe  of  Girdner.  Its  employ- 
ment does  not  necessitate  the  use  of  any  battery,  as  the  operating  current 

Fig.  is. 


Girdner's  telephonic  probe  ready  for  use. 

is  taken  directly  from  the  body  of  the  patient.  Tlic  instrument,  which 
consists  of  receiver,  wires,  bidb,  and  ])robe,  is  thus  described  by  Dr. 
Girdner.'     Fig.  1(S  rejiresents  the  instrument  ready  for  use. 

'  To  eacli  of  the  binding  posts  of  the  receiver  attach  one  end  of  each  of  the  con- 
ducting wires,  O,  O.     To  tlie  free  end  of  one  of  these  wires  attach  the  bulb,  C,  to  the 


452  GUNSHOT   WOUNDS. 

When  the  aluniiiium  probe  is  passed  into  the  wound  no  current  is 
obtained  wliile  it  touches  the  flesh,  because  it  is  the  same  metal  as  the 
bulb  in  the  mouth,  but  so  soon  as  this  probe  touches  the  leaden  bullet 
tlie  circuit  is  completed,  a  current  passes,  and  the  fact  is  announced  liy 
a  loud  clickinu;  in  the  receiver  at  the  ear.  If  the  probe  used  was  of 
any  other  metal  than  the  bulb  in  the  mouth,  the  current  would  be  estab- 
lisiietl  as  soon  as  it  touched  the  flesii  in  passinij  into  the  track  of  the 
bullet.  Hence  it  becomes  an  axiom  that  the  bulb  in  the  mouth  and  the 
probe  at  the  end  of  the  other  wire  must  be  of  tlie  same  metal  and  differ- 
ent from  the  metal  sought  for.  If  this  condition  is  kept  in  view,  any 
metal,  as  silver,  copper,  etc.,  may  l)e  used  for  the  bull)  and  jtrobe. 

"  The  shafts  of  the  probes  are  insulated  by  being  enclosed  in  a  fine 
rubber  tube  which  can  be  I'emoved  for  cleansing  and  replaced.  This, 
was  found  necessary  because  the  end  of  the  probe  might  fail  to  touch 
the  bullet,  and  the  shaft  touch  it  some  way  back  from  the  point,  and 
thus  deceive  the  surgeon  as  to  the  exact  dcjith  of  the  missile.  It  also 
sometimes  happens,  where  tlie  bullet  has  entered  tlie  cranial  cavity,  that 
a  piece  of  the  lead  is  torn  off  and  lodged  just  within  the  external  wound, 
while  the  main  portion  has  jienetrated  deeper.  In  such  a  case,  if  the 
shaft  were  not  insulated,  all  efforts  to  locate  the  main  body  of  the  missile 
would  be  frustrated  l)y  the  continual  responses  caused  by  the  shaft  of 
the  probe  coming  in  contact  with  the  sliver  of  lead  lying  on  the  side 
of  the  track  made  by  the  l)ullet. 

"  When  the  telephonic  bullet  probe  is  used,  there  is  never  any  ques- 
tion whether  a  hard  substance  felt  in  a  wound  is  bone  or  Indlet" 
(Girdner).     '\\'^hcn    the    former  is  touched,   nothing    is    heard    "  but    a 

free  end  of  tlie  otlier  attach  the  probe-hantlle,  and  in  the  sUit  of  the  hancUe  place  the 
probe,  or  needle,  you  wish  to  use;  be  certain  all  binding  posts  are  tightly  screwed  and 
electi-ical  contact  perfect  at  each  joint,  and  the  instrnmcnt  is  ready  for  use. 

Place  the  bulb,  (',  in  the  patient's  mouth — ('.  c.  between  the  teeth  and  the  cheek  in 
the  buccal  cavity — taking  care  tliat  the  ninisturc  in  the  mouth  makes  a  perfect  electrical 
contact  between  bulb  and  cheek  ;  the  o)ierator  holds  the  receiver  to  his  ear  with  one  hand, 
as  when  listening  in  a  speaking  telephone,  while  with  the  other  hand  he  passes  the  probe, 
P,  into  the  wound  in  search  of  the  bullet.  Nothing  will  be  heard  until  tlie  probe  tonches- 
the  bullet,  when  there  will  be  heard  a  distinct  rasping,  grating,  or  clicking  sound  in  the 
receiver,  and  you  know  certainly  that  the  probe  has  located  the  missile.  The  lighter  the 
contact  of  the  probe  with  the  bullet,  the  louder  the  sound  heard;  continuous  contact  of 
probe  with  bullet  ])roduees  a  contimioun  current,  and  hence  no  sound  in  the  receiver;  the 
•inlerriipird  current,  produced  by  making  and  breaking  the  contact  when  the  probe  is 
gently  passed  over  the  little  irregularities  on  the  surface  of  the  bullet,  is  what  ]uoduces- 
the  sound  in  the  receiver  at  the  ear. 

It  is  well  to  experiment  with  the  instrnnient  before  using  it  in  actual  practice,  and 
for  that  purpose  place  the  bulb  in  the  buccal  cavity  of  an  assistant,  and  after  tlioruiic/hly 
nvttiiifi  one  of  his  hands  place  in  that  hanil  a  piece  of  lead  large  enough  to  enalile  him  to 
grasp  itfirndy  ;  then  the  operator  places  the  receiver  to  bis  ear  and  probes  the  lead  in  the 
assistant's  hand  by  gently  passing  the  probe  over  it,  and  he  will  find  no  sound  produced 
in  the  receiver  wlien  the  finger-nails  or  flesh  of  the  hand  is  touched,  Ijut  the  slightest 
touch  of  the  probe  to  the  lead  causes  a  grating  sound.  The  hand  holding  the  lead  must 
be  Lrpt  wer  or  the  instrument  will  not  work. 

Ry  ex]ierimenting  in  ibis  way  the  ear  becomes  trained,  so  that  there  is  no  trouble  in 
determining  the  presence  or  .aliseuee  of  a  bullet  in  a  wound  probed.  There  is  liotli  a 
steel  and  an  alumimim  bulb  in  the  case,  and  also  aluminum  probes  and  steel  needles; 
when  an  aluminum  probe  is  used,  the  aluminum  bulb  must  be  used  on  the  other  wire, 
but  the  steel  bulb  mu.st  be  used  if  it  is  desired  to  use  the  needles.  The  needles  are  to  he 
thrust  through  the  tissues  in  searching  for  the  bullet  when  its  course  has  been  so  tortuous 
that  it  cannot  be  followed  by  the  probe,  or  in  cases  of  old  gunshot  wounds  when  the  mis- 
sile is  still  in  the  tissues  and  the  track  made  by  the  bullet  has  healed. 


jMISSILES.  453 

characteristic  clicking  or  grating  when  lead  is  touched  and  gently 
rubbed.     This  sound,  once  heard,  is  never  forgotten  "  (Girdner). 

Tliough  this  and  other  electric  appliances  have  at  times  been  found 
of  service,  their  use  has  been  too  limited  to  indicate  their  real  value. 
As  it  would  seem  at  present,  only  exceptionally  are  they  likely  to  be 
employed. 

Its  position  having  been  determined,  whether  or  not  the  bullet  should 
be  extracted  \\ill  depend  upon  how  much  damage  will  j)robaI)ly  be  done 
in  searcliing  for  and  n-moving  it,  and  the  projxtrtioii  of  such  danger 
relative  to  that  consequent  uptm  leaving  the  ball  in  place.  It  may  be 
taken  out  either  through  the  track  of  the  wound  or  through  a  counter- 
opening,  according  as  the  one  or  the  other  is  most  convenient  and  least 
harmful,  l)ut  under  no  circumstances  should  the  bullet  be  cut  for  unless 
its  position  lias  been  positively  determined. 

If  cut  down  upon,  care  must  be  taken  to  hx  it  tirmly  while  the 
incision  is  being  made,  and  that  it  may  be  readily  removed  it  must  be 
thoroughly  exposed.  Its  extraction  may  be  effected  by  the  use  of  a 
special  bullet-forceps  (of  which  that  which  is  long,  slender,  its  blades 
toothed,  and  one  of  them  preferably  fenestrated  and  having  two  short 
teeth  (U.  S.  Army  pattern),  will  lie  found  most  generally  servicealile), 
or  it  may  be  caught  by  any  firm-bladed  forceps  ;  not  seldom  an  ordinary 
hiiemostatic  or  seciuestrum  forceps  will  prove  effective.  In  the  military 
practice  of  the  future  the  removal  of  bullets  will  doubtless  be  of  ex- 
ceedingly infrequent  occurrence,  as  only  very  rarely  will  the  momentum 
of  the  shot  be  so  reduced  as  to  permit  of  lodgement. 

The  impression  has  long  prevailed  that  gunsluit  wounds  do  not  bleed, 
nor  do  they,  at  least  those  of  the  soft  parts,  but  exceptionally  as  they 
come  under  care.  At  the  time  of  the  injury  hemorrhage  does  occur, 
and  aside  from  those  shot  through  the  head  the  majority  of  the  wounded 
who  sj)eedily  die  do  so  from  loss  of  blood.  But  unless  a  large  trunk 
has  been  opened  the  bleeding  quickly  subsides,  natural  hremostasis  tak- 
ing place,  and  even  if  it  is  a  large  vessel  the  hemorrliage  mav  not  cause 
early  death.  During  our  late  war  cases  were  under  treatment  in  liospital 
in  which  upon  autopsy  it  was  found  that  the  vertebral,  carotid,  sub- 
clavian, axillary,  and  common  iliac  arteries,  and  the  internal  jugular, 
internal  iliac,  and  femoral  veins,  had  been  opened.  There  has  come 
under  personal  observation  a  case  of  pistol-shot  division  of  the  super- 
ficial and  deep  femoral  arteries  and  the  superficial  femoral  vein,  in 
which  dentil  did  not  occur  for  ten  hours,  and  one  of  the  left  subclavian 
artery  in  wiiich  it  was  delayed  vuitil  the  eleventh  day.  Severe  or  fatal 
primary  hemorrhage  may  he  expected  to  be  more  common  in  wounds 
made  by  the  new  bullet  than  it  used  to  be,  though  it  may  prove  other- 
wise, since  there  will  be  none  of  the  extensive  tearing  that  was  often 
produced  by  the  irregular,  deformed,  jagged  soft-lead  ball.  Secondary 
hemorrhage,  that  formerly  was  so  common  and  so  fatal,  will  \)v  infre- 
quent in  ]n-oportion  as  an  aseptic  condition  of  the  wound  is  secured  and 
maintained. 

The  jiain  accompanying  a  gunshot  wound  is  very  variable  in  amount, 
according  to  the  velocity  of  the  ball,  the  part  injured,  and  the  sensibility 
of  the  individual,  natural  or  for  the  time  being.  Occasionally  acute,  it 
is  more  generally  dull  and  tingling,  the  part  often  feeling  as  if  it  luul 


454  GUNSHOT   WOUNDS. 

been  struek  with  a  stick.  Under  lii^^h  excitement  no  pain  may  be 
experienced  tor  a  time,  even  thoiifih  tlie  injury  is  a  severe  one. 

Siiock,  like  pain,  is  ordinarily  experienced  by  one  who  has  been  sliot, 
and  is  commonly  most  mai'ked  in  those  whose  wounds  are  of  the  brain 
or  spinal  cord  or  of  parts  intimately  connected  with  the  solar  plexus.  It 
varies  in  amount  from  that  which  is  very  slight  to  that  which  is  quickly 
destructive  of  life.  Its  symptoms  are  often  blended  with  those  of  col- 
lapse;  indeed,  in  the  majority  of  cases  the  nervous  distuii)auces  are 
largely  secondary  to  the  primary  disturliance  of  the  circulation.  As 
respects  diagnosis  and  prognosis,  the  most  important  of  these  svnij)toms 
is  a  lowering  of  the  body-heat.  After  careful  observation  of  fifty  cases 
during  the  siege  of  Paris,  Redard  declared  that  "  a  fall  of  temperature  is 
a  constant  phenomenon.  Every  wounded  man  brought  to  field  hospital 
presenting  a  temjierature  lower  than  .j5.5°  C  (about  96°  F.)  will  suc- 
cumb, and  conse(|Ueiitly  it  is  useless  in  such  eases  to  resort  to  any  opera- 
tion. Every  wounded  man  in  whom  a  salutary  reaction  does  not  come 
on  by  the  end  of  the  fourth  hour,  and  in  whom  the  reaction  is  not  in 
direct  proportion  to  the  fall  (of  temperature  previously),  ought  to  be 
considered  as  in  a  verv  serious  state.  Penetrating'  wounds  of  the  alidomen 
produce  an  exceptionally  low  fall  of  temperature,  which  is  more  marked 
as  the  stomach  is  apj)roached.  M'ounds  by  shell,  other  tilings  being 
ecpial,  produce  a  more  marked  fall  of  temjterature  than  those  by  ball." 

The  ultimate  result  of  a  gunshot  wound  depends  upon  the  size  and 
velocity  of  the  vulnerating  body,  the  parts  injured,  and  the  early  and 
after  treatment  I'cceived.  Its  fatality  is  consequent  upon  shock,  hemor- 
rhage, and  septic  infection  ;  the  first  two  being  the  causes  of  death 
occurring  quickly,  the  last  that  of  the  great  majority,  certainly  more  than 
two-thirds,  of  the  cases  coming  under  professional  care.  Due  regard  to 
this  fact  must  be  had  in  studying  the  mortality-rate  of  any  given  wound, 
the  statistics  that  have  been  accumulated  being  in  large  measure  those 
of  army  practice,  of  cases  not  treated  aseptically  or  treated  so  only  in  a 
very  limited  degree.  Recovery  from  pistol-shot  injury  is  of  far  more 
likely  occurrence  than  from  a  wound  made  by  a  service  bullet,  old  or 
new,  the  lesion  being  not  so  great  and  the  case  ordinarily  coming  under 
care  more  speedily. 

Shock  and  primary  hemorrhage  may  be  expected  to  be  as  great  or 
greater  in  the  wars  of  the  future,  in  which  use  will  be  made  of  the  small- 
calibre  bullet,  as  in  those  of  the  past ;  but  the  death-rate  of  cases  coming 
under  treatment  will  l)e  very  greatly  reduced  if  tiie  wouiuled  can  be 
protected  from  erysipelas,  septicaemia,  gangrene,  and  tetanus,  all  these 
lieing  infective  diseases  the  causes  of  which,  and  the  means  of  prevent- 
ing which,  have  in  large  measure  been  ascertained  only  in  the  last  few 
years  and  since  the  time  of  any  great  war. 

The  organisms  causing  the  infection  of  a  shot  wouml  may  lie  introduced 
on  the  bullet,  carried  in  on  a  jiiece  of  clotli  or  other  foreign  body,  be 
present  in  the  blood  extravasated  into  the  damaged  area,  or  introduced 
upon  finger  or  instrument  employed  in  exploration  and  treatment. 

Rarely  will  the  bullet  be  the  carrier  of  infection,  but  the  carefully- 
conducted  experiments  of  La  Garde  and  Messncr  show  that  pathogenic 
organisms  are  not  necessarily  destroyed  by  the  heat  of  the  firing — a  heat 
which  V.  Beck  has  proved  to  be  much  less  than  is  common!)'  supposed, 


MISSILES.  455 

the  temperature  of  the  recovered  titeel-jacketed  cal.  .30  shot  being  but 
78°  C,  and  of  the  copper-jacketed  one  110°  C.  v.  Coler  and  Schjer- 
ning  have  found  tliat  in  passing  tin-ougli  ])orti<)ns  of  the  human  body  the 
temperature  of  a  projectile  only  in  excejitional  cases  exceeds  95°  C. 

Infection  through  the  medium  of  a  jtieee  of  clothing  may  be  expected 
to  occur  as  often  as  sucii  piece  is  carried  in  ;  but  the  pointed,  small-calibre, 
swift-moving  bullet  will  leave  it  in  the  track  much  less  frequently  than 
did  the  old-time  ball.  If  this  is  the  only  infection  of  the  wound,  the 
ett'ect  mav  be  but  a  slight  one,  and  that  readily  overcome,  and  if  the  l)it 
of  cloth  is  not  removed  or  spontaneously  extruded,  it  may  be  encapsulated 
and  thus  rendered  harmless. 

Germ-laden  blood  will  without  doubt  be  occasionally  poured  out  of 
the  torn  vessels  to  poison  the  wound-area,  but  practically  this  source  of 
infection  may  be  disregarded.  In  wounds  of  the  intestines  a  constantly 
present  and  potent  cause  of  sepsis  is  to  be  found  in  the  contents  of  the 
canal. 

Bv  far  the  most  common  and  most  important  media  of  infection  are 
the  hands  and  finders  of  the  surtreon  and  dresser  and  the  instruments 
that  are  introduced  into  the  wound.  There  was  certainly  much  truth  in 
Nussbaum's  declaration  that  the  fate  of  a  woinided  man  is  in  the  hands 
of  the  surgeon  who  first  attends  him.  In  civil  practice  infection  of 
srunshot  lesions  other  tiian  abdominal  is  in  verv  lartre  measure  due  to 
uncleanly  examinations  and  dressings.  It  is  to  abstention  from  active 
interference  with  the  wound,  either  altogether  or  until  it  could  be  done 
aseptically,  and  to  rigid  antiseptic  after-treatment,  that  M'e  are  to  attrib- 
ute the  generally  successful  result  that  has  of  late  years  been  had  in 
the  non-visceral  wounds  treated  in  the  hospitals  of  our  country,  and  the 
nnich  less  fatality  of  wounds  of  the  head,  the  chest,  and  the  abdomen. 
How  far  it  may  be  possible  in  war  to  prevent  septic  infection  by  pri- 
mary dressings  and  later  care  experience  only  will  determine.  The  con- 
ditions under  which  the  wound  is  received,  the  length  of  time  that  often 
must  elapse  before  any  assistance  can  be  rendered,  the  movings  that 
must  be  made,  the  hurried  dressings  that  not  seldom  must  be  applied — 
all  the  unfavorable  conditions  of  field  practice — will  combine  to  limit,  it 
may  be  in  high  degree,  the  asejiticity  that  can  be  secured.  On  board 
ship  much  l)etter  opportunity  will  be  afforded  to  carry  out  in  detail  the 
modern  woinid-treatment. 

Wounds  produced  by  large  shot  or  large  fragments  of  exploded 
shells  as  they  come  under  observation  are  usually  very  extensively  lace- 
rated, even  uj)  to  complete  or  nearly  complete  carrying  away  of  the 
part  struck.  At  times,  as  has  already  been  stated,  the  skin  may  re- 
main apparently  intact  though  widespread  pulpification  of  nuiscle  and 
great  comminution  oT  bone  have  taken  place.  The  momentum  of  even 
the  nearly  "spent  shot"  is  sufficient  to  produce  very  serious  injnrv,  and 
soldiers  have  long  recognized  the  danger  there  is  in  attempting  to  stop 
the  progress  of  a  round  shot  slowly  rolling  on  the  ground.  Occasion- 
ally balls  or  fragments  of  several  pounds'  weight  have  lodged  in  the 
body,  even  escaping  early  detection.  The  only  question  of  interest  that 
is  likely  to  jiresent  itself  in  relation  to  these  severe  injuries  is  whether 
or  not  prompt  removal  of  the  ])art  shall  be  done  or  an  attempt  made  at 
conservation.     When  amputation  is  decided   upon,  it  must  be  borne  in 


456  GUNSHOT   WOUNDS. 

mind  tliat  tlie  muscle-lesion  at  least  is  not  limited  to  the  ]iart  struck  ; 
consec|uently  the  operation  nuist  be  done  at  a  level  well  ahove  tliat  of 
the  wound.  In  civil  practice  extensive  injury  is  often  ])r<)duced  by  a 
charge  of  "  small  shot "  at  short  range  acting  as  a  single  ball  or  scatter- 
ing but  little.  If  the  main  vessels  or  nerves  of  the  region  are  not 
involved  in  the  destruction,  conservative  treatment  may  frecpu'iitly  be 
successfully  adopted,  though  ani])utation  or  (if  tliere  is  shattering  of  a 
joint)  cxsection,  complete  or  partial,  will  often  be  required.  In  the 
"  small-shot "  wounds  at  a  distance  of  more  than  a  few  feet  conserva- 
tism should  be  the  rule,  the  lodged  shot  being  removed  or  left  accord- 
ing as  their  extraction  is  easy  or  otherwise.  In  a  limited  number  of 
cases  serious  injury  is  done  by  these  small  missiles,  as  in  tlie  eye,  the 
larynx,  or  the  antcro-lateral   regions  of  the  neck. 

Treatment. — The  two  most  important  elements  of  the  treatment  in 
general  of  these  wounds  are  the  prevention  of  infection  and  the  secur- 
ing of  rest.  Bullets  may  or  may  not  liave  to  be  sought  for,  bone-frag- 
ments may  or  may  not  have  to  be  removed,  torn  vessels  may  or  may  not 
have  to  be  tied,  but,  that  promjit  repair  may  take  place,  everv  gunshot 
wound  must  be  made  and  kept  aseptic  or  so  antisc[)tical]y  treated  that 
suppuration  will  occur  in  but  a  limited  degree;  and  by  immobilization, 
so  far  as  it  may  be  practicable  to  establish  it,  the  damaged  area  must  be 
kept  quiet.  In  the  majority  of  pistol  M'ounds,  other  than  those  neces- 
sarily mortal,  when  they  are  treated  in  the  ordinary  aseptic  and  antisep- 
tic way  tlie  prognosis  is  good  and  repair  may  be  cx])cctcd  to  take  jilace 
prom])tly.  The  wounds  made  l)y  the  new  Ijidlct  will  witimut  doul)t  be 
found  to  heal  nuich  more  quickly  than  those  produce<l  l>y  the  oltl  large- 
calibred,  soft-lead  bullet.  As  a  rule,  the  closing  of  the  track  com- 
mences in  its  central  portion  and  proceeds  thence  toward  the  wounds 
of  entrance  and  of  exit,  the  former  commonly  healing  last  of  all.  Such 
closure,  especially  in  lesions  of  the  soft  jiarts,  may  and  frecjuently  does 
occur  without  suppuration  ;  more  often  the  jius-formation  is  slight,  and 
chiefly  in  and  near  the  entrance  wound,  and  this  even  tliough  bone  has 
been  damaged.  It  is  the  recognition  of  these  facts  that  is  leading  sur- 
geons more  and  more  to  treat  at  least  pistol-ball  injuries  in  the  most 
simple  manner,  actively  interfering  with  the  wounds  only  when  pain, 
heat,  and  swelling  make  it  evident  that  foreign  bodies  are  to  be  re- 
moved or  free  drainage  secured.  When,  in  consequence  of  small-shot 
injury  of  an  extremity  inflicted  at  very  short  range,  or  of  a  rifle-ball 
laceration  within  the  zone  of  explosive  action,  or  of  a  crush  by  a  large 
shot  or  a  large  fragment  of  shell,  a  limb  is  very  extensively  mangled, 
amputation  will  generally  be  required,  or,  but  less  often,  an  exseetion. 
It  will,  however,  doulitless  be  found  that  such  operations  will  be  much 
less  frequently  demanded  in  the  future  tiian  they  were  in  former  times, 
just  as  it  is  now  with  cases  of  extensive  compound  fractures  due  to 
traumatisms  other  than  gunshot. 

The  primary  effects  of  a  gunshot  wound  (shock,  pain,  and  hem- 
orrhage) are  to  be  treated  in  the  ordinary  way.  As  has  already  been 
stated,  bleeding  in  any  considerable  amount  is  not  of  frequent  occur- 
rence in  the  generality  of  flesh  wounds,  though  a  moderate  degree  of 
oozing  during  some  hours,  or  even  days,  may  lie  expected.  Bone  wounds 
are  attended  with  a  greater  loss  of  blood,  but,  as  commonly  met  with 


EFFECTS   UPON  THE    VARIOUS  TISSUES  457 

in  civil  life,  the  iu'iiiorriiage  in  connection  witli  them  does  not  necessi- 
tate any  special  treatment.  In  the  lesions  of  tlie  liead,  chest,  and  abdo- 
men serions  hemorrhage  very  often  is  present,  and,  as  we  siiall  see  iiere- 
aftcr,  in  many  cases  demands  prompt  operative  interference  ;  and  the 
same  is  trne  of  wonnds  of  the  neck,  tiie  axilla,  and  the  groin.  W'liere 
vessels  of  larger  size,  arteries  or  veins,  have  been  torn,  recourse  must 
be  had  to  either  compres.sion  or  ligation.  Compression  often  answers 
a  good  purpose  when  jmiperly  and  methodically  a[)])lied,  more  so  in 
cases  of  vein-wounds  tlian  in  those  of  arteries,  but  wlien  tlie  l>Iecding 
is  at  all  ])rofuse  tlie  wounded  vessel  should  be  freely  exposed  and  tied 
above  and  below  the  point  of  injury.  Chemical  styptics — e.g.  tiie  per- 
salts  of  iron — should  never  be  employed :  again  and  again  they  have 
proved  inefficient  and  their  use  productive  only  of  evil.  If  cold  (or, 
much  better,  h(it)  water  does  not  stop  the  bleeding,  compression  or  the 
ligature  siiould  l)e  applied.  In  a  few  of  tiie  cases  in  which  the  main 
artery  and  vein  of  a  limb  have  been  sinudtaneonsly  lacerated  am[)utation 
may  have  t(j  be  performed  to  prevent  the  occurrence  of  gangrene  of  tiie 
extremity. 

Secondary  hemorrhage  when  it  takes  place  (and  it  may  occur  at  a 
very  late  day)  will  ordinarily  necessitate  ligation  of  the  vessel — in  the 
wound  if  possible  ;  if  not,  well  above  the  level  of  injury — thougli  at 
times  com])ressiou  has  proved  of  service,  or  even  the  laying  open  of  the 
wounded  part.  Wiiether  or  not  ligation  should  be  done  when  tiie  vessel 
is  not  bleeding  has  long  been  a  question.  There  may  be  no  recurrence 
of  the  hemorrhage,  and  the  disturbance  of  the  wound  necessary  to  the 
tying  can  only  increase  the  gravity  of  the  situation ;  on  the  other  hand, 
if  ligation  is  not  done,  a  later  l)leeding  may  occur — fatal  it  may  be,  cer- 
tainly adding  to  tlie  existing  danger.  As  a  general  rule,  the  wisest 
course  is  not  to  ojierate  after  a  first  bleeding,  but  to  do  so  always  after  a 
second.  There  is  every  reason  to  believe  that  in  the  military  practice 
of  the  future  secondary  hemorrhage  will  be  much  less  frequent  than 
heretofore,  due  as  it  is  to  suppurations  and  septic  processes  that  can  be 
largely  prevented  by  antiseptic  treatment.  In  civil  practice  secondary 
bleeding  is  of  very  infrequent  occurrence. 

Effects  upon  the  Various  Tissues. 

Skin. — According  to  the  velocity  of  the  bullet  and  the  angle  at  which 
it  strikes,  the  skin  may  be  merely  grazed,  strongly  contused,  or  jicne- 
trated.  In  the  former  case  there  will  be  developed  an  erythema  which 
will  soon  subside,  or  a  superficial  devitalization  mav  be  efil'ctcd,  causing  the 
formation  of  a  thin  dry  slough,  the  separation  of  which  will  be  followed 
by  slight  scarring.  'When  the  contusion  has  been  more  severe,  without 
material  injuiy  to  the  parts  beneath,  under  antiseptic  treatment  the  slough 
(which  may  include  the  entire  thickness  of  the  derm)  will  still  be  dry, 
and  when  its  se]iaration  takes  place  it  will  be  found  tiiat  there  has  l)een 
healing  under  the  crust.  In  rare  instances  the  elasticity  of  the  skin  will 
prevent  its  laceration,  although  the  tissues  beneath  are  extensivelv  crushed, 
as  has  been  observed  in  certain  cases  when  the  part  has  been  brushed  by 
a  large  shot  or  massive  piece  of  shell  in  full  flight  or  struck  by  such  when 
nearly  spent.     Not  seldom  when  the  ball  ])asses  for  quite  a  distance  just 


458  GUNSHOT   WOUNDS. 

iin<l(>r  tho  skin  its  trnok  will  he  marked  hv  a  deeji  diseoloration  of  the 
iiiteti'iiineiit,  and  the  at'ter-sejiaratidn  of  the  slough  will  leave  a  depressed 
guttered  wound,  and  later  a  eicatrix. 

Fascia. — The  formerly  often-observed  deflection  of  a  ball  by  a  layer 
of  firm  deep  fascia  very  rarely  occurs  when  the  wound  is  j)roduced  by  a 
pistol  shot  of  to-day,  and  can  never  do  so  when  the  missile  is  one  of  the 
new  army  bullets.  The  fascial  fibres  being  in  considerable  measure 
separated  rather  than  torn,  some  closing  in  of  the  openings  through  the 
layers  may  be  expected,  which  may  render  ])robing  more  difficult  and 
drainage  less  free  and  complete.  It  is  not  likely  that  surgeons  of  the 
future  will  see,  other  than  very  exceptionally,  permanent  openings  with 
rounded  edges  in  the  outer  layer  of  the  deep  fascia,  through  which  hernial 
protrusion  of  muscle  can  occur— openings  tliat  were  frequently  the  result 
of  wounds  made  by  round  balls  and  the  earlier-employed  large  conical 
bullets. 

Muscles. — As  made  by  bullets,  except  within  the  zone  of  explosive 
action — and  there  is  no  such  zone  with  reference  to  jiistol  shots — muscle- 
wounds  are  not  attended  with  any  extensive  destruction  of  tissue,  and  the 
associated  blood-extravasations  arc  not  large.  When  the  shot  jiasses  in 
the  line  of  the  muscular  filircs  there  may  often  lie  separation  rather  than 
destruction,  rendering  it  very  difficult,  it  may  be  impossible,  to  follow  the 
track.  Passing  transversely,  though  the  laceration  may  be  quite  great, 
there  is  very  seldom  a  complete  severing  of  the  muscle.  ^Mien  struck 
by  large  shot  or  a  large  piece  of  an  exploded  shell  widespread  destruction 
is  effected,  with  resulting  great  loss  of  substance  and  the  after-formation 
of  an  extensive  and  deep  scar.  Tendons  are  more  often  severed,  but  as 
a  rule  a  piece  is  cut  out  or  a  perforation  made.  At  times  the  impact  of 
the  shot  causes  a  rupture  of  the  muscular  belly  above,  the  tendon  itself 
being  only  contused.  Whether  or  not  the  tendon  will  often  be  pushed 
out  of  the  way  by  the  new  bullet,  and  thus  escape  injury,  remains  to  be 
seen. 

Blood-vessels. — Arteries  and  veins  in  the  track  of  the  modern  bul- 
let, pistol  or  rifle,  especially  the  latter,  will  rarely  if  ever  be  uninjured. 
As  before,  they  may  be  completely  or  partially  divided  or  may  be  con- 
tused, with  liability  to  the  later  occurrence  of  hemorrhage  or  the  formation 
of  an  aneurism.  Associated  perforation  of  both  artery  and  vein  may  be 
followed  l)y  the  development  of  an  arterio-veuous  aneurism. 

Nerves. — Contrary  to  what  was  formerly  true,  nerve-trunks  are  less 
likely  to  l)e  damaged  than  the  larger  blood-vessels.  When  in  tho  path 
of  the  ball  they  generally,  however,  are  torn  or  contused,  with  resulting 
impairment  or  entire  loss  of  motion  or  sensation  ;  pain  of  greater  or  less 
severity  and  continuance,  at  times  burning  (causa/c/ia) ;  trophic  changes  ; 
or  absolute  destruction  of  the  vitality  of  the  parts  to  which  they  are 
distributed. 

Boxes  and  Joixts. — Among  the  more  serious  lesions  met  with  in 
military  practice  are  wounds  of  bones  and  joints,  which  constitute  about 
one-fifth  to  one-fourth  of  all  the  injuries  coming  under  care.  In  civil 
life  the  proportionate  number  is  much  smaller  and  their  gravity  is  as  a 
rule  nmch  less,  caused  as  they  generally  are  by  bullets  of  less  weight 
and,  still  more,  less  velocity. 

A  bone  injured  may  be  either  contused  or  fractured  according  to  the 


EFFECTS   UPON  THE  BONES.  459 

angle  at  which  it  is  struck,  and,  especially,  the  momentum  of  the  bullet. 
Contusions  jn'oduced  by  pistol  balls,  more  often  of  course  those  of  small 
calibre,  are  frequently  of  sucli  sliu'ht  severity  (mere  jarrings)  that  their 
existence  is  unsuspected  or  thought  probaljle  only  because  the  missile, 
flattened  out  it  may  be,  is  found  resting  against  the  bone.  More  often, 
the  blow  being  stronger,  some  subperiosteal  extravasati(.)n  occurs,  and  in 
a  limited  number  of  cases  the  impact  of  the  shot  is  sufficient  to  destroy 
vitality,  the  necrosed,  later  separated,  piece  of  bone  varying  nuich  in 
tiiickness. 

Musket-liall  contusions,  which  were  formerly  not  uuconunon,  and 
were  often  followed  by  local  and  general  septic  infection,  will  in  all  prob- 
ability be  almost  or  quite  unknown  in  the  future,  the  new  rifle  bullet 
fracturing,  not  bruising,  any  bono  that  it  may  strike.  Antiscptically 
treated,  the  bone-contusions  may  be  expected  to  lie  rapitlly  recov- 
ered from  without  either  permanent  thickening  or  persistent  neuralgia 
resulting. 

Fractures  are  of  various  kinds,  according  to  the  force  and  angle  of 
impact,  the  character  of  the  bone  struck,  and  in  the  long  bones  the  part 
injured,  whether  in  the  shaft  or  near  the  extremity.  Whatever  they  may 
be,  they  are,  in  general,  due  to  contact  or  penetration,  the  former  being 
mediate  or  immediate,  the  result  of  a  tangential  or  a  direct  blow  ;  the 
latter  partial  or  complete,  tiie  Ijall  entering  and  remaining,  or  passing 
entirely  through  to  lodge  in  the  soft  parts  or  emerge  tiu'ough  the  skin. 
The  simplest  form  of  contact-injury  is  a  mere  crack,  of  greater  or  less 
length,  curving  oftentimes  at  its  extremities — a  lesion  of  little  moment, 
very  frequently  overlooked,  and  recognizable  with  great  difficulty  except 
upon  actual  inspection.  Percussion,  by  developing  the  "  cracked-jiot " 
sound,  lias  at  times  been  of  diagnostic  value,  and  it  may  be  that  evidence 
of  importance  may  be  affi)rded  by  the  pain  in  a  limited  area,  which  has 
been  shown  to  be  produced  by  the  passage  of  a  galvanic  current  tin-ough 
a  broken  bone. 

As  an  exaggeration  of  this  linear  fracture  there  may  be  a  fissure,  the 
edges  of  the  crack  separating  somewhat,  in  a  superficial  lione  ])ermitting 
of  recognition  of  the  gap  upon  palpation.  When  such  fractures  are  pro- 
duced by  direct  strolce,  the  missile  must  have  in  large  measure  lost  its 
momentum.  Rarely,  but  probably  more  often  than  has  been  sup])osed, 
the  crack  or  fissure  may  extend  transversely  or  obliquely  through  the 
entire  thickness  of  the  bone,  causing  the  simplest  form  of  a  complete 
fracture,  and  in  a  few  cases  such  sej)aration  has  been  found  to  have 
occurred  not  in  the  area  directly  injured,  but  at  a  level  considerablv  above 
or  below.  Because  of  tiie  al)sence  of  nniscular  traction  upon  them,  or 
of  an  incomplete  tearing  of  the  periosteum  over  them,  the  fragments  may 
remain  in  apposition,'  to  be  perhaps  later  separated  by  movements  of  the 
part  or  by  muscular  contractions  after  the  untorn  periosteal  bands  have 
softened.  These  contact-fractures,  which,  as  has  already  been  stated, 
will  often  be  overlooked,  require  no  special  treatment.  If  protected  from 
infectiiiu  and  the  injured  area  is  innnobilized,  rapid  repair  will  take 
place. 

It  is  by  penetration  that  the  great  majority  of  fractures  are  produced, 
the  essential  character  of  the  injury  being  a  driving  in  of  the  part  of  the 
bone  struck,  with  or  without  associated  fissures  passing  out  in  various 


460 


GUNSHOT   ]VOUi\I)S. 


directions  and  to  varyinjj  distances  (Figs.  19,  20,  21,  22,  23,  and  24 
are  from  tiie  report  of  ^Vsst.  yurg.  La  Garde,  U.  S.  A.,  Report  of  the 
tiuiycon-Geiierat  of  the  Army,  l&Vo). 

Fig.  19. 


Gunshot  injury  by  the  ."30-calibre  German  silver  Jaclteted  projectile,  possessed  with  the  velocity 

usual  at  2000  yards. 


Flu.  iO. 


Posterior  view. 


The  central  depression  may  be  lint  sliglit,  even  absent  altogether  ■\vhcn 
examination  i.s  made,  having  been  overcome  by  the  elasticity  of  the  osse- 
ous tissue,  or  the  piece  of  bone  may  be  forced  in  (to  the  medullary  cavity, 
for  example,  in  a  long  bone,  or  %vithin  the  cranium  in  a  skull-injury), 
or  it  may  be  completely  pulverized  and  its  dust  driven  out  of  the  body 
or  scattered  along  the  track  of  the  ball,  the  differences  in  the  condition 
of  the  ])iece  directly  struck — and  they  are  very  wide — depending  upon 
the  shape,  size,  and  hardness  of  the  bullet  and  its  velocity.  The  iissures 
passing  out  from  the  centre  of  violence  are  also  very  variable  in  num- 
ber and  extent,  ranging  from  a  scarcely  perceptible  crack  to  a  complete 
breaking  up  of  the  bone.  When  the  fracture  is  in  the  shaft  of  a  long 
bone  the  characteristic  fissuring,  as  Dclorme  has  .shown,  is  that  of  an 
elongati'd  x  (Figs.  25  and  26),  the  four  primary  parts  of  which  may  be 
secondai'ily  .split  into  a  few  or  many  pieces.  Sometimes  the  .sj)lintering 
extends  into  or  through   the  epiphysis ;  occasionally  it  ends  abruptly 


EFFECTS   UPON  THE  BOXES. 


4(J1 


above  and  below  in  an  ahno.-;t  transverse  break,  tlie  intervenins;'  portion 
of  the  shaft  being  spHt  up  into  many  completely  separated  wedge-shaped 


Fig.  21. 


Injury  liy  the  ,"30-calibre  German  silver  jacketed  projectile,  with  the  velocity  common  at  1200 
yarfis.  The  oritice  of  entrance  has  a  puuched-out  appearance  eiiual  iu  diameter  to  that  of  the 
projectile. 

Fig.  22. 


Posterior  view  :  fissures  are  exaggerated  by  drying. 

fragments,  sneh  condition  being  consequent  upon  an  injury  at  siiort  range. 
It  has  long  been  recognized  that  the  number  and  size  of  the  fragments 

Fig.  23. 


Injury  liy  the  ."30-calibre  German  silver  jacketed  projectile,  with  the  velocity  common  at  1200 

yards. 

Fig.  24. 


Posterior  view. 


are  in  inverse  proportion  to  the  velocity  of  the  missile.     The  sequestra 
may  be  entirely  detached  or  partially  adherent — /.  c  primary  or  .second- 


462 


G UNSiio T  war tnds. 


arv.  Ill  ])ist()l-shot  wounds  few  of  them  are  likely  to  be  found  free,  and 
tiiese  ordinarily  small,  and  in  the  wounds  made  by  the  new  bullet  in  the 
middle  ranges  the  fragments  are  mueh  more  largely  adherent  than  they 
were  in  the  wounds  formerly  observed.  Very  fre(|ut'ntly  ])istol  balls 
have  foree  enough  only  to  fraeture  the  bone  or  to  ])enetrate  its  substance 
for  a  short  distance. 

When  tlie  wound  is  located  in  the  epiphysis  or  in  tiie  juxta-ejiiphvs- 
eal  area,  and  the  injury  has  not  been  inilicted  at  short  range,  splinter- 
ing is  nuich  less  than  when  it  is  in  the  shaft  of  the  bone,  a  clean  pcrfor- 

FiG.  25. 


Gunshot  injurv  of  the  right  femur  at  junction  of  miihlle  and  upper  thirds  by  the  ."30-ealibre  German 
silver  jaclc'eted  projectile,  with  the  velocity  common  at  awo  yards  (Asst.  Surg.  La  Garde,  V.  S. 
A.,  loci  cit.). 

Fig.  26. 


Posterior  view. 


ation  with  little  or  no  associated  fissuring  being  often  observed  (Figs. 
27  and  28). 

Almost  or  <|uite  as  clean  a  jierforation  may  occur  at  .some  dis- 
tance above  the  articulating  e.xtrcmity,  as  illustrated  by  Figs.  29 
and  30. 

As  in  the  case  of  wounds  of  the  diaphysis,  the  ball  may  remain 
external  to  the  bone,  lodge  in  it,  or  pass  thn)Ugh  it,  but,  because  of  the 
lessened  resistance  of  the  cancellous  tissue,  is  more  likely  to  ])erforate, 
making  a  comparatively  clean  canal,  with  an  outlet  wound  commonly  a 
little  larger  than  the  bullet. 

AVounds  of  the  irregular  bones  much  resemble  those  of  the  sj)ongy 
extremities  of  the  long  bones,  but  because  of  their  small  size  these  bones 
may  be  expected  to  be  largely  sjilintored,  without,  however,  in  many 
cases,  much  sepai-ation  of  the  fragments. 

The  flat  bones  may  be  extensively  shattered  or  perforated,  as  is  much 


EFFECTS   UPON  THE  BOXES. 


4(;3 


more  often  the  case  now  than  in  former  times.  The  perforation  will 
commonly  be  found  to  be  somewhat  eunical,  its  edge  on  the  side  of  exit 
being  more  or  less  bevelled  at  the  expense  of  the  outer  layers.  Such 
perforation  may  or  may  not  be  associated  with  fissures  running  for  a 
variable  distance  into  the  bone. 

Ever  since  the  adoption  of  the  conical  bullet  military  surgeons  have 
observed  that  there  is  a  marked  difterence  in  the  damage  done  to  bone 
according  to  the  range.     The  destruction  produced  by  a  shot  at  compar- 


FiG.  27 


Perforation  bv  the  ."30-calibre  German  silver  iaclceteti  projectile,  with  the  velocity  common  at  1200 
yards.  The  diameter  of  the  traeli  of  the  bullet  in  the  bone  corresponds  to  the  diameter  of  the 
missile  (Asst.  Surg.  La  Garde,  U.  S.  A.,  loc.  cit.). 


Fig.  28. 


Posterior  view. 


atively  .short  distance  is  so  enormous  that  it  seems  as  if  the  bullet  nnist 
have  been  an  explosive  one,  and  within  such  distance  has  been  placed 
the  "zone  of  explosive  action."  With  the  old  liullet  it  extended  to  200 
to  250  yards,  sometimes  a  little  more ;  with  the  new  it  is  increased 
to  350,  400,  or  even  500  yards.  As  La  Garde  (Asst.  Surg.  U.  S.  A.) 
has  stated  it :  "  There  are  no  special  features,  as  a  rule,  to  describe  about 
the  wounds  of  entrance,  except  the  appearance  at  times  of  bony  .sand  in 
the  tract  leading  to  a  fractured  bone.  When  a  resistant  bone  has  been 
hit,  the  foyer  of  fracture  will  show  great  loss  of  substance  :  the  bone 


464 


GUNSHOT   WOUNDS. 


will  have  been  driven  n(it  only  in  the  direction  in  whieh  the  projectile 
■was  travelling,  but  in  all  directions,  and  the  pulpifieation  of  the  soft 
parts  will  not  be  limited  only  to  the  track  of  the  bullet,  but  the  utter 
destruction  is  noticed  some  distance  into  the  tissue.     The  wound  of  exit 

Fig.  29. 


Injury  Ijy  the  ."30-calibre  German  silver  jacketed  projectile  with  the  velocity  common  at  120O 
yards.  The  fissure  occurred  in  drying ;  it  was  not  present  in  the  recent  state  lAsst.  Surg.  La 
Garde,  U.  S.  A.,  loc.  cit.). 

Fig.  30. 


Posterior  view. 


appears  like  a  bursting  forth  of  the  skin  ;  the  track  leading  to  the  bone 
is  conical  in  shape,  the  base  of  the  cone  corresiionding  to  the  wound  of 
exit  in  the  skin,  and  the  apex  to  the  seat  of  fracture." 


EFFECTS   UPOX  THE  BOXES. 


465 


In  certain  cases  the  exit  wound  has  been  found  to  have  a  length  of 
four,  six,  or  even  more  inches,  and  a  width  of  three  or  four,  and  occa- 
sionally honc-fra<inu'nts  driven  out  have  jjierccd  tiie  shin  at  j)oints  out- 
side of  the  main  laceration.  No  very  marked  ditferenccs  have  been  found 
to  exist  between  the  destructive  effects  of  the  old  and  the  new  missiles, 
though  doubtless  those  of  the  latter  are  somewhat  less.  In  the  woimds 
produced  l)y  pistol  ixdls  no  explosive  action  takes  jilace,  tlieir  momentum 
not  being  sutticiently  great.  Perhaj)s  in  small  measure  due  to  the  sway- 
ing of  the  ball,  the  axial  rotation  of  whicli  has  not  become  fully  settled, 
practically  the  immense  destruction  effected  within  the  zone  of  explosive 
action  is  due  to  hydraulic  pressure,  and  is  pro])ortionate  to  the  fluidity 
of  the  tis.sue  struck.  At  distances  outside  the  zone  of  explosive  action, 
anil  up  to  a  range  of  1200  to  1500 — it  may  be  even  2000 — yards,  bone- 
wounds  made  by  the  now  bullet  are  of  least  severity  ;  and  it  is  in  this 
"middle  distance"  that  there  occur  clean  ])erforations  or  perf\)rations 
with  the  formation  of  a  few  though  large  fragments,  and  these  chiefly, 
it  may  be  almost  wholly,  adherent.  Beyond  a  distance  of  1500  or  2000 
yards  connninution  and  disj)lacemcnt  of  fragments  again  become  greater, 

Fig.  31. 


Complete  perforation  in  the  upper  part  of  the  shaft  of  the  left  tibia  by  the  ."30-calibre  German 
silver  jaekete'l  projectile,  with  the  veloeitv  common  at  V2W  yards.  There  is  also  an  injury  in 
the  mi'idic  of  the  shaft  by  a  ."3n-calil>ru  prcpjectile  at  the  same  range.  The  bullet  struck  the 
crest  "f  the  tibia,  passing  wholly  in  fmni  of  the  medullary  canal,  guttering  the  crest.  There 
is  a  complete  fracture  (..\sst.  Surg.  La  Oarde,  U.  S.  A.,  loc.  cit). 

Fig.  32. 


Posterior  view. 


the  result  doubtless  of  the  wabbling  of  the  sliot ;  and  such  smashing  of 
the  bone  continues  up  to  the  extreme  range  of  fracturing. 

When  it  is  a  ridge  or  crest  of  bone  that  is  .struck,  or  the  ball  crosses 
a  curved  surface  tangent  ially,  guttering  is  often  produced  (Figs.  31  and 
32),  the  notch  or  furrow  being  at  times  quite  clean  cut,  at  times  as.so- 
ciated  with  fl.ssurings.  A  ball  im|)inging  upon  a  ridge  or  ercst  may  be 
split  into  two  pieces  of  nearly  iMpuil  or  very  unequal  size,  either  entirely 

Vol.  I.— .'iO 


466  GUNSHOT  WOUNDS. 

separated  or  held  togctlier  at  tlic  haso.  Similar  splitting  is  occasionally 
found  when  it  is  the  convex  surltiee  of  the  skull  that  has  been  struck. 
The  hardened  lead  pistol  ball  is  niueli  less  likely  to  be  affected  in  this 
way  than  is  the  soft  lead  one,  and  sncii  splitting  will  not  occur,  or  only 
exceedingly  seldom,  wlien  the  missile  is  a  jacketed  rifle  ball. 

Tiiat  fracture  by  jK'uetration  lias  occurred  may  or  may  not  be  easy 
of  determination.  A\'hen  crepitus  is  recognized,  deformity  is  present, 
preternatural  mobility  exists,  and  the  functional  integrity  of  the  limb 
is  lost  (in  other  words,  when  there  are  the  ordinary  symptoms  of  frac- 
ture), there  can  be  no  question  respecting  the  diagnosis,  particularly  so 
if  in  addition  there  are  bonc-fragmcnts  or  bone-dust  in  the  track  of  the 
ball  and  the  exit  wound  is  of  large  size.  Thi'  bone-fragments,  if  found 
at  all,  will  be  between  the  bone  and  the  outlet  wound,  except  in  inju- 
ries within  the  explosive  zone,  when  at  times  small  fragments  are  also 
carried  back  toward  the  orifice  of  entrance.  As  a  general  rule,  a  length 
of  exit  wound  exceeding  an  inch  indicates  that  there  has  lieen  bone- 
injury  ;  and,  as  Delorme  has  shown,  a  fairly  safe  conclusion  as  to 
whether  or  not  sucli  injury  has  lieen  received  may  be  drawn  from  inspec- 
tion of  the  exit  hole  in  the  clothing,  whicii  is  very  generally  larger  in 
cases  of  fracture  than  in  those  of  wounds  of  the  soft  parts  only.  But 
small  size  of  perforation-wounds  by  no  means  indicates  absence  of  bone- 
lesion  or  its  limited  extent.'  Occasionally,  in  the  absence  of  other 
signs,  ]>erforation  is  made  certain  by  the  presence  of  evidences  of  injury 
of  a  viscus  wiiicli  could  only  have  been  reached  after  the  ball  iiad  jiassed 
through  the  overlying  bone. 

When  the  symptoms  mentioned  are  wanting  and  the  lesion  is  rendered 
likely  only  because  of  the  direction  of  the  shot,  it  will  often  be  the 
wiser  course  to  be  content  with  the  establishment  of  a  jirobable  diag- 
nosis, since  in  the  effort  to  secure  certainty  the  l)onc-iiijurv  may  be 
much  aggravated  and  the  after  condition  of  the  patient  made  much 
worse. 

The  primary  treatment  must  of  course  vary  with  the  extent  of  bone- 
injury.  \\^hen  this  is  but  slight,  thorough  cleansing  of  the  external 
wound,  and,  as  far  as  it  may  be  practicaldc,  of  the  track,  being  effected, 
the  part,  if  the  lesion  is  in  an  extremity,  siiould  be  innnobilized.  If 
more  severe,  comjjletely  detached  fragments  should  be  removed  if  they 

'  In  illustration  of  the  truth  of  this  statement  niav  be  qnoted  a  recent  report  of  an 
experimental  case  observed  l)y  Lt.-Col.  Stevenson  of  the  British  army,  }irofessor  of 
military  surgery  at  Netley.  The  tiring  was  done  at  a  50  yards'  range.  "The  bullet 
passed  through  the  ankle-joint,  entering  the  astragalus  behind,  above  the  surface  for 
articulation  witli  the  os  calcis,  and  passed  out  in  front  through  the  neck  of  the  bone. 
The  skin-wounds  were  very  small,  that  of  entrance  being  a  little  less  in  diameter  than 
the  bidlet,  and  that  of  exit  a  little  smaller  than  the  former.  On  dissection  it  was  found 
that  the  bullet  had  passed  through  tlie  astragalus  about  half  an  inch  beneath  the  artic- 
ulating surface  for  the  tibia.  All  the  astragalus  except  its  head  was  pulverized,  and  all 
its  articulating  surfaces  s]ilit  except  that  for  the  scajihoid.  The  lower  end  of  the  tibia 
was  fissured  in  many  directions,  and  to  a  certain  extent  pulverized,  although  the  bullet 
had  not  actually  touched  any  part  of  this  bone.  The  cause  of  this  condition  of  the 
tibia  was  evidently  the  bursting  apart  of  the  astragalus  while  firmly  held  by  the  grasp 
of  the  two  malleoli.  The  attachment  of  the  external  malleolus  of  the  fibula  to  the  outer 
surface  of  the  tibia  did  not  give  way,  and  the  internal  malleolus  was  not  fractured;  thus 
'it  was  that  when  the  bullet  passed  through  the  astragalus,  greatly  distending  that  portion 
of  the  bone  held  between  the  malleoli,  the  articulating  surface  of  the  tibia  was  sjilit  and 
the  lower  end  of  the  bone  extensively  fissured." 


EFFECTS   UPON  THE  BOXES.  467 

can  readily  be  gotten  at,  the  canal  drained,  the  limb  imniobilizetl,  and 
antiseptic  treatment  maintained  nntil  healing  takes  place.  Fragments 
which  are  adherent  should  be  left  in  })lacc,  after  having  been  as  much 
as  possil)le  ])ressed  intd  position  if  found  to  be  decidedly  tilted  off  from 
the  normal  line  of  the  bone.  Not  infrequently  a  sequestrum  which  is 
ajjparently  entirely  separated  is  really  fastened  at  one  extremity  by  peri- 
osteal bands,  and  its  removal  can  be  accomplished  only  with  difficulty 
and  with  resulting  increase  of  damage  to  the  bone.  When  so  fastened 
it  should  be  treated  as  an  adherent  fragment,  since  if  sepsis  is  prevented 
its  vitality  will  probably  be  preserved,  and  if  not  it  i-ui  be  extracted 
later.  Until  recently  the  general  rule  has  been  to  remove  an  impacted 
ball,  wound-infection  being  almost  certain  to  occur,  and,  if  the  foreign 
body  was  left,  necrosis  of  greater  or  less  extent  of  the  bone  was  quite 
sure  to  follow  ;  and  now,  if  the  missile  can  be  located  and  readily  taken 
awav,  such  removal  should  be  made.  But  if,  as  is  so  generally  the  case 
in  pistol-shot  injuries  in  civil  life,  to  find  and  remove  the  bullet  necessi- 
tates doing  much  damage  to  the  parts,  it  had  better  be  left  undisturbed. 
If  protected  from  wound-infection  the  injured  urea  will  generally  do 
W'cll,  whether  the  missile  is  left  or  is  taken  away.  When  the  shot  has 
gone  through  and  out  and  the  crushing  has  not  been  very  great,  as  it 
will  not  be  except  at  short  range,  the  same  general  principles  t)f  treat- 
ment must  govern  the  conduct  of  the  surgeon — removal  of  se])a rated 
fragments  (and,  as  has  already  been  stated,  they  will  be  found  between 
the  bone  and  the  wound  of  exit),  antiseptic  cleansing,  and  dressing  and 
immobilization  of  the  part.  When  there  has  been  great  destruction  (as 
from  a  rifle  ball  within  the  explosive  zone,  a  load  of  shot  from  a  gun 
but  a  few  feet  away,  a  large  shot,  or  a  shell  fragment),  whether  or  not 
the  liml)  can  be  siived  will  depend  upon  the  extent  of  comminution  and 
the  amount  of  injury  done  the  soft  parts.  Gunshot  fractures,  so  far  as 
treatment  is  concerned,  do  not  differ  materially  from  other  compound 
fractures,  and  if  it  is  possible  to  employ  the  same  methods  of  cleansing 
and  dressing,  similar  good  results  may  be  expected.  In  military  ]>ractice, 
from  the  necessities  of  the  situation,  thorough  and  rigid  antise])tic  treat- 
ment cannot  be  applied  otiier  than  exceptionally,  but  from  the  limited 
experience  of  the  hist  twenty  years  it  may  be  reasonaldy  hoped  that 
much  can  be  done  to  lessen  the  old-time  mortality  of  bone-injuries.  In 
civil  life  amputation  will  be  required  only  when  the  limb  has  been 
extensively  shattered,  and  not  even  then  in  many  cases  unless  there  is 
an  associated  laceration  of  the  main  vessels  or  nerves.  But  on  the  field, 
removal  of  the  limb  is  called  for  not  only  when  there  has  been  great 
shattering  of  bone  with  or  without  extensive  laceration  of  the  soft  parts 
and  injiuy  of  vessels  and  nerves,  or  when  a  portion  of  the  extremity 
has  been  completely  devitalized  or  has  been  carried  away,  but  also  in  less 
severe  cases  because  of  the  unhealthy  surroundings  of  the  soldier,  the 
existing  necessity  of  transporting  him  long  distances,  and  the  limited 
attention  that  it  may  be  possible  to  afterward  give  him.  Neither  in 
civil  nor  in  military  practice  should  anq>utation  be  done  when  there  is 
a  reasonable  probability  of  sjiving  a  tolerably  useful  limb,  even  though 
such  limb  be  deformed  or  the  source  of  some,  it  may  be  considerable, 
discomfort.  Often  has  it  hap))ened  to  surgeons  in  our  country  in  tiie 
last  thirty  years  U>  see  amjmtation  stumps  that  were  painful,  frequently 


468  GUNSHOT   WOUNDS. 

iilconiting',  and  of  little  fuiictidnal  value.  Formal  cxsections  in  the 
shafts  of  the  long  hones,  operations  "  in  continuity,"  should  not  be 
done,  more  of  the  bone  l^eing  taken  away  and  the  end  results  being  less 
satisfactory  than  when  there  has  been  an  informal  removal  of  non- 
adherent sequestra. 

Later  in  the  progress  of  the  case,  as  in  ordinary  comjionnd  fractures, 
removal  of  the  limb  may  have  to  be  made  because  of  infective  processes 
in  the  part,  sujipurations,  osteomyelitis  acute  or  chronic,  or  gangrene. 
Even  under  the  most  rigid  antiseptic  treatment  compression-gangrene 
necessitating  amputation  may  occur. 

Joint-wounds. 

These  are  either  extra-  or  intra-articular,  and,  like  those  of  bone,  are 
of  greatly  varying  degrees  of  intensity.  The  several  joints  vary  much 
in  liability  to  injury  according  to  their  anatomical  position  and  their 
exposure  to  traumatism.  As  generally  stated,  in  order  of  frequency  are 
found  lesions  of  the  shoulder,  knee,  elbow,  wrist,  ankle,  hip,  though  in 
our  late  war  the  wounds  of  both  knee  and  elbow  were  more  numerous 
than   those  of  the  shoulder. 

Extra-articular  injuries  might  well  be  considered  simply  as  wounds 
of  the  soft  parts,  were  it  not  for  the  fact  that  at  times,  either  because  of 
injudicious  examinations  or  more  often  of  extension  of  septic  inflamma- 
tion, the  synovial  membrane  is  ojiened  and  the  joint  involved.  A  seton 
wound  may  be  present,  or  a  eonsideralile  extent  of  the  coverings  of  the 
articulation  may  be  carried  away  or  later  destroyed  by  gangrene. 
Tendon-sheaths  are  often  opened  with  or  without  injury  of  the  tendons, 
and  sometimes  because  of  such  openings  there  is  so  much  discharge  of 
synovia-like  fluid  as  to  lead  to  the  erroneous  diagnosis  of  actual  jienetra- 
tion  of  the  joint.  The  old-time  round  ball  occasionally  ran  around  the 
joint  through  a  large  arc,  and  some  have  believed  that  it  is  not  impos- 
sible for  the  conical  iiall  to  take  a  similar  curved  course  :  the  probabili- 
ties are,  however,  that  in  the  cases  in  which  such  wounds  have  seemed 
to  exist  the  ball  really  passed  sti'aight  from  entrance  to  exit,  })iercing  the 
joint-cavity,  but  speedy  closure  of  the  middle  part  of  the  track  occurred 
and  the  joint-lesion  gave  rise  to  no  wcll-detinod  symptoms. 

Intra-articular  wounds  may  be  due  to  the  direct  entrance  of  the  ball 
from  without  or  througli  one  of  the  bones  of  the  joint,  to  primary 
laceration  of  the  synovial  membrane  in  connection  with  a  bone-fissure 
or  later  opening  by  ulceration,  or  to  crushing  of  the  parts  by  a  large 
shot  or  a  shell  fragment.  As  a  rule  having  few  exceptions,  a  bullet 
passing  through  the  joint  damages  one  or  both  of  the  bones  entering 
into  its  composition,  fissuring,  canalizing,  grooving,  or  notching  it  or 
them.  In  the  knee  it  may  traverse  the  u]iper  pouches  of  the  synovial 
membrane  M'ithout  causing  osseous  lesion,  or  if  the  leg  is  somewhat 
flexed  upon  the  thigh  (at  an  angle  of  from  150°  to  170°),  it  may  pass 
from  side  to  side  below  the  patella  without  impinging  upon  either  femur 
or  tibia. 

That  a  joint  has  been  injured  may  be  readily  determined  when  there 
has  been  extensive  Iacerati()n  ;  when  upon  palpation  much  comminution 
is  found  to  exist ;  when  great  fulness  of  the  synovial  cavity  is  rapidly 


JOINT-  WO  rXDS.  469 

developed,  showing:  that  tlicre  has  been  a  large  extravasation  of  blood 
into  the  joint  ;  when  there  is  free  diseliarge  of  mingled  blood  and 
synovia  from  the  wound  of  entrance  or  of  exit  or  from  both  ;  or  when 
bone-dust  or  fragments  are  found  in  the  exit  wound.  But  when  none  of 
these  symptoms  are  present  the  diagnosis  must  rest  upon  impairment 
of  funetioii,  ujion  escape  of  synovia,  and  upon  the  position  of  the  wounds 
of  entrance  and  exit  with  reference  to  the  articulation.  Inability  to  use 
the  limb  has  little  or  no  signiticance,  as  it  may  be  an<l  often  is  associated 
with  an  extra-articular  injury.  Escape  of  synovia  in  limited  amount 
may  be  from  an  opened  tendon-sheath.  Of  much  greater  value  is  the 
direction  of  the  line  joining  the  wounds,  for  it  may  be  very  confidently 
assumed  that  when  tiiis  line  leads  through  the  joint  a  conical  ball,  pistol 
or  rifle,  has  gone  througii  tlie  articulation.  In  the  knee  and  elliow,  less 
often  at  tiie  ankle,  by  digital  pressure  crepitus  and  yiekiiug  of  fragments 
may  frequently  be  detected.  The  appearance  of  the  wound  gives  no  sure 
indication  of  the  condition  of  tiie  parts  within.  As  has  been  truly  said, 
"that  which  more  than  everything  else  characterizes  these  injuries  is  the 
insignificant  lesion  of  tiie  fibrous  and  cutaneous  envelopes,  concealing 
damage,  often  very  considerable,  of  the  cutis  of  the  bones."  Probing 
in  doubtful  cases  should  not  be  resorted  to,  for  it  may  open  a  previously 
intact  capsule.  Accuracy  of  diagnosis  is  not  necessary  in  such  cases,  the 
wound  being  regarded  as  an  articular  one  and  treated  accordingly  in  a 
conservative  way.  When  the  bullet  has  passed  through  the  epiphysis  the 
splintering  is  likely  to  be  confined  to  it;  when  tiu'ough  the  juxta- 
epipiiyseal  area  it  will  jirobably  affect  botli  the  eiiiphysis  and  the  lower 
part  of  the  iliaphysis.  The  tissuring  at  times  is  both  radiating  and 
circular.  The  ex|)erimeuts  made  with  tiie  new  bullet  show  tiiat  in  the 
middle  ranges  canalization  with  little  or  no  splintering  will  often  be  pro- 
duced, especially  in  those  articular  extremities  that  contain  much  cancel- 
lous tissue.  Commonly  the  sefpiestra  are  few  and  but  little  displaced. 
M'itiiin  tile  zone  of  explosive  action  great  destruction  is  effected.  In  a 
limited  number  of  cases  there  are  complicating  lesions  of  large  vessels 
or  nerves,  as  also  at  times  of  tiie  chest  and  abdomen,  in  injuries  of  the 
shoulder  and  hip. 

The  prognosis  in  these  joint-wounds  lias  always  been  grave,  even  in 
the  accidents  of  civil  life.  The  average  mortality  of  the  cases  tabulated 
by  Longmore  was  32. 2o  per  cent.,  and  of  tiiose  occurring  during  our  late 
war  33.58  per  cent.,  and  as  respects  the  various  articulations  ranged 
from  12.9  |)er  cent,  in  wounds  of  the  wrist  to  85  per  cent,  in  those  of  the 
hip.  But  these  are  the  death-rates  of  cases  not  protected  by  the  treat- 
ment of  to-day  agiiinst  the  septic  infections,  and  to  such  infections  from 
three-quarters  to  nine-tenths  of  the  mortality  has  been  due.  It  cannot 
but  be  tiiat  in  future  wars,  however  defective  the  wound-dressings  uiav 
be  because  of  the  conditions  necessarily  associated  with  field  service,  there 
will  be  a  saving  of  a  much  increased  ])roportion  of  those  shot  througii 
the  articulations.  In  civil  practice  the  proliabilities  of  recovery  are  now 
great,  and  a  fatal  result  of  an  uncomplicated  joint-wound  is  not  to  be 
expected. 

Heretofore,  in  cases  tliat  have  not  died  and  in  which  amputation  has 
not  been  done,  the  functional  value  of  tlic  jirescrved  limb  has  usually 
been  far  from  very  good.     Ankylosis,  eitiier  true  or  false,  to  a  greater  or 


470  GUNSHOT  WOUNDS. 

less  extent,  has  been  present  in  the  hirge  niajority,  the  fixation  often 
being  angular  antl  det'orniing ;  frequently  chronie  osteomyelitis,  with 
consequent  bone-fistulfe,  has  been  observed  ;  dangle-joints  have  followed 
many  of  the  extensive  resections;  and  an  irritable  neuralgic  condition 
of  the  damaged  part,  lasting  for  years  (U'  during  the  whole  after-life  of 
the  wounded  man,  has  often  been  experienced.  Here,  again,  it  is  to  be 
hoped — indeed,  expected — that  the  future  will  be  better  than  the  past, 
since  in  no  small  measure  the  difficulties  mentioned  have  been  due  to,  or 
at  least  much  aggravated  by,  sujipurative  inflammations.  Protected  from 
such,  it  has  more  than  once  been  shown  that  even  lodgement  of  a  foreign 
body — e.  r/.  a  bullet — in  the  articulation  may  not  pre\-ent  recovery  with 
free  mobility  of  the  joint. 

Tile  treatment  of  joint-wounds  is  either  by  expectancy,  by  excision, 
or  by  amputation.  Expectancy,  which  includes  removal  of  foreign 
bodies  (bullets,  free  sequestra,  etc.),  is  a  method  of  treatment,  as  we  will 
see  later  when  considering  the  lesions  of  special  joints,  the  adoption  of 
which  in  the  past  was  at  the  risk  of  great  danger  to  ])art  and  life  in 
\\ounds  of  other  than  very  minor  gravity.  Supj)urations,  necroses,  gen- 
eral infective  diseases,  either  death  or  late  amputation, — such  was  too 
often  the  record  in  the  cases  of  articular  injuries  treated  conservatively ; 
but  as  it  is  now  possible  in  wounds  in  civil  life  to  prevent  the  develop- 
ment of  morbid  processes  consequent  upon  the  action  of  pyogenic  organ- 
isms, either  wlioUy  or  in  great  measure,  rarely  shoidd  any  other  than 
conservative  treatment  be  adopted — never,  except  when  there  has  been 
such  destruction  of  the  joint  and  parts  about  as  to  make  it  impossible  to 
save  the  limb,  or  to  save  it  with  reasonable  expectation  of  its  being 
serviceable.  Not  even  the  laceration  of  the  main  vessels  or  nerves 
absolutely  compels  primary  amjiutation. 

In  a  rigidly  antiseptic  way  loose  fragments  of  bone  and  pieces  of 
cloth  should  lie  removed,  and  the  bullet  also  if  it  has  lodged  and  the  size 
of  the  canal  permits  of  its  being  readily  reached  and  extracted.  Com- 
monly, the  diameter  of  the  track  is  small  and  the  bullet  is  firmly  fixed 
in  position,  so  that  more  harm  will  likely  be  done  in  finding  the  ball  and 
taking  it  away  than  by  the  missile  itself  if  left  undisturbed.  The  wound 
and  the  skin  about  the  orifice  of  extrance  and  exit  having  been  thor- 
oughly cleansed,  the  limb  should  be  antiseptii'ally  dressed  and  immo- 
bilized in  the  same  manner  as  in  the  case  of  an  articular  traumatism 
other  than  gunshot.  If  largely  distended  with  blood,  the  joint  should 
be  aspirated.  The  effort  to  render  the  wound  aseptic  and  to  maintain  it 
so  failing,  the  resulting  suppurative  inflammation  will  ordinarily  be  of 
limited  extent  and  is  to  be  treated  in  the  usual  manner. 

Though  experience  only,  and  that  the  large  one  of  a  great  war,  Mill 
definitely  settle  tlie  question,  tiiere  is  every  ])robal)ility  that  the  joint- 
wounds  produced  by  the  new  small-calibred  bullet  will  in  large  measure 
be  safely  and  satisfactorily  treated  expectantly  ;  and  bullet  wounds  will 
be,  as  they  always  have  been,  the  great  majority  of  articular  lesions.' 
Septic  arthritis,  when  it  ai-ises,  is  to  be  treated  by  free  incisions,  thorough 
cleansing,  and  the  maintenance  of  full  drainage.  Formerly  common,  it 
will  doubtless  hereafter  be  developed  in  l)ut  a  limited  number  of  cases, 

'  In  our  late  war  they  were  ribniit  87  per  cent. ;  in  the  last  three  Prussian  wars,  93 
per  cent. ;  94.5  per  cent,  in  that  of  1870-71. 


WOUNDS  OF  SPECIAL  JOINTS.  All 

those  in  wliich  either  the  primary  disinfection  of  the  wound  has  been 
defective  or  tiie  after-treatment  has  failed  of  preventing  the  occurrence 
of  snp|)iiration  or  infective  osteomyelitis.  If  upon  opening  up  the  artic- 
ulation extensive  destruction  of  Ixine  is  found  to  exist,  amputation  or 
excision  should  be  resorted  to,  tliough  tiie  probability  of  recovery  is  not 
very  great. 

The  extreme  fatality  of  lesions  of  the  major  articulations  treated 
expectantly  during  the  wars  of  the  first  half  of  this  century  led  to  the 
establishment  of  the  rule  that  in  such  injuries  amputation  or,  much  less 
often,  excision  should  be  done — a  rule  very  generally  observed  during 
the  wars  of  the  third  quarter,  though  removal  of  the  damaged  part,  rather 
than  of  the  limb,  was  more  freely  resorted  to,  especially  in  wounds  of 
the  shoulder  and  elbow.  Even  under  such  treatment  the  mortality-rate 
was  high,  33.5  per  cent,  of  the  joint-wounds  in  our  late  war  terminating 
fatally,  chiefly  because  of  septic  infection. 

In  all  probability,  in  the  future  amputation  will  be  done  only  when 
tlicrc  has  been  extensive  crushing  of  the  joint  and  parts  about,  or  the 
articular  wound  is  complicated  by  such  vessel-  or  nerve-injury  as  to  pre- 
vent tiie  preservation  of  the  vitality  of  the  limb.  Excision  (which  dates 
back  to  the  time  of  ]\Ioreau  and  Percy)  will  be  done  but  seldom,  not 
l)ecause  of  its  fatality,  for  that  will  l)e  greatly  reduced  (it  is  now  only 
about  one-eighth  of  what  it  was  in  pre-asc])tic  times),  but  because  the 
end-result  of  the  operation  is  not  so  good  as  tliat  following  conservative 
treatment.  Gurlt,  having  studied  the  after-history  of  652  soldiers  upon 
whom  resections  had  been  done  during  the  late  German  wars,  found  that 
there  was  good  functional  use  of  the  limb  in  less  than  37  per  cent,  of  the 
cases ;  limited  use,  and  that  often  only  when  jirothetic  a]i])aratus  was 
employed,  in  50  per  cent.  ;  and  in  more  than  13  ])er  cent,  the  liml)  was 
useless,  or  worse,  a  burden.  It  is  much  to  be  regretted  that  no  one  has 
in  a  similar  manner  determined  and  reiwirted  the  end-results  of  the  1346 
cases  of  excision  of  one  or  other  of  the  six  larger  joints  during  our  late 
war  which  are  known  to  have  recovered  from  the  operation.  Were  it 
possible  to  operate  subperiosteally,  such  regeneration  might  be  expected 
as  woidd  materially  increase  the  functional  value  otherwise  secured,  but 
in  a  ])rimary  operation  for  gunshot  injiu'v  only  very  exceptionally  can  the 
periosteiun  be  saved,  and  the  attempt  to  do  so  is  almost  always  but  a 
waste  of  time. 

Wounds  of  Special  Joints. 

Shoulder. — About  2  per  cent,  of  all  wounds  received  in  action  are 
of  this  articulation,  and  about  one-sixth  of  ;dl  the  articular  lesions.  The 
injury  is  almost  always  one  of  penetration,  the  ball  citiier  striking  the 
joint  or  fracturing  the  humerus,  and,  througii  s])lintering,  opening  the 
.synovial  cavity.  In  war  the  left  joint  is  more  often  wounded  than  the 
right,  because  of  its  advanced  position  in  infantry  firing.  With  cavalry- 
men the  reverse  is  true,  the  right  shoulder  being  carried  forward  in  the 
use  of  the  sabre  or  pistol.  The  degree  of  injury  caused  ]>y  the  new 
bullet,  except  at  short  range,  will  doubtless  prove  to  be  decidedly  less 
than  by  the  old,  canalization  being  largely  effected,  with  but  a  moderate 
amount  of  associated  splintering  and  nnich  less  separation  of  the  frag- 
ments.    Lodgement  of  the  bullet,  occasionally  observed  heretofore,  is 


472  GUNSHOT  WOUNDS. 

not  to  be  expected  ;  even  in  tlie  pistol  wounds  of  civil  life  the  ball 
rarely  fails  to  perforate.  Determination  of  the  part  of  the  hunierus 
struck,  whetlier  head  or  neck,  annti>nii('al  or  surgical,  must  rest  usually 
upon  the  positions  of  the  wounds  of  entrance  and  of  exit,  and  is  really 
a  matter  of  very  little  importance.  That  a  fracture  of  any  kind  has 
occurred  will  often  be  knt)\vn  only  from  the  direction  of  the  shot,  the 
fragments  being  so  held  together  that  neither  crejiitus,  preternatural 
mobility,  nor  deformity  can  be  discovered. 

The  prognosis  may  now  l)e  regarded  as  very  good  in  cases  uncom- 
jilicatcd  with  lesions  of  the  larger  vessels  or  nerves  or  of  the  chest,  and 
in  individuals  whose  personal  condition  and  hygienic  surroundings  are 
not  bad.  Formerly  it  was  otherwise  ;  the  mortality-rate  during  our 
war  was  34  per  cent.  But  statistics  of  date  prior  to  twenty  years  ago 
liave  only  an  historic  value. 

The  treatment  in  civil  life  is  l)y  expectancy,  and  doubtless  will  be 
so  hereafter  in  army  practice.  Amj)utation  will  be  reserved  for  cases 
of  extensive  crushing  and  of  associated  laceration  of  the  important 
structures  in  the  axilla.  Even  in  these  last  conservatism  will  be 
largely  employed  in  non-military  traumatisms.  When  both  scapula 
and  clavicle  are  injured,  as  well  as  the  humerus,  it  may  at  times  be 
advisable  to  amputate  high  up,  doing  an  interscapulo-thoracic  opei'ation 
after  the  method  of  Bergcr. 

Excision,  which  was  so  much  favored  and  so  extensively  practised  in 
the  ten  years  between  1861  and  1871,  will  rarely  be  employed,  for  it 
has  proved,  as  observed  in  our  own  country  and  in  Germany,  that  the 
late  condition  of  the  great  majority  of  those  thus  ojierated  upon  is  far 
from  being  satisfactory,'  and  a  more  useful  lind)  may  reasonably  be 
expected  to  be  secured  by  conservative  treatment.  Moi'eover,  so  far  as 
we  may  infer  from  the  experience  of  our  late  war,  excision  is  more 
dangerous  than  either  conservatism  or  amputation  (36.6  per  cent.  ;  27.5 
per  cent.  ;  29.1  per  cent.),  and,  though  the  present  wound-treatment  will 
greatly  reduce  the  mortality-rate,  the  reduction  must  apjily  ef|ually  to 
the  three  methods  of  treatment. 

Elbow. — These  injuries,  which  constitute  about  one-tenth  of  the 
wounds  of  the  upper  extremity,  are  occasionally  jieriarticular,  but  very 
generally  perforative,  the  missile  rarely  lodging.  In  a  few  instances 
the  capsule  has  been  opened  without  any  bone-lesion  being  produced, 
usually  when  the  forearm  is  somewhat  flexed  and  the  ball  has  passed 
just  above  the  olecranon. 

The  extra-articular  wounds,  pro{)er]y  treated,  are  of  importance  only 
as  there  is  serious  nerve-injury  or  because  of  hemorrhage. 

As  in  other  articular  lesions,  the  extent  of  damage  to  the  bones  varies 
within  wide  limits,  but  in  a  large  projiortion  of  the  cases  as  now  met 
with  comminution  is  not  great,  and  the  fragments  are  chiefly,  it  may  be 
entirely,  held  in  close  relation  with  each  other.  The  humerus,  the  ulna, 
or  the  radius  may  be  wounded,  or  any  two  of  them,  or  all  three  in  the 

'  In  213  cases  Giirlt  found  that  there  were  but  4  in  which  the  functional  value  of 
the  limb  was  very  satisfactory  (1.87  per  cent.),  90  in  which  it  was  good  (42.25  per  cent.), 
and  in  119  it  was  either  Ijad  or  very  bad  (55.88 per  cent.).  After  conservatism  in  former 
times  an  ankylosed  shoulder  was  usually  present  (in  seven-eighths  of  the  cases,  according 
to  Chenu) ;  after  excision  there  was  often  a  dangle-joint. 


WOUNDS  OF  SPECIAL  JOINTS  473 

extensive  crushings  of  the  joint.  The  lesion  of  the  Immerns  may  be 
confined  to  an  epicondyle,  may  affect  only  the  articulating  surface  below 
the  epiphyseal  line,  or  may  be  located  in  or  just  above  that  line.  At 
the  present  time  it  may  be  ex])ected  to  be  less  extensive  than  formerly, 
wlien  the    soft-lead,    large-caliltre    ball 

was  used,  an  illustration  of  the  destruc-  ''^^'  ^^' 

tive  action  of  which  is  giv^en  in  Fig.  33. 

As  a  rule,  the  precise  character  of 
the  injury  can  be  determined  only  with 
difficulty,  except  so  far  as  it  is  indicatctl 
by  tiie  direction  of  the  line  joining  tlie 
wounds  of  entrance  and  exit.     E([ually 
as  a  rule,  such  determination  is  of  little         •"'>"'  '' a°^L  m°  spe^il^""'''"' 
practical  value.     The  complicating  in- 
juries are  of  the  arteries,  usually  the  braciiial,  and  of  the  nerves,  the 
ulnar  being  much  more  often  the  one  wounde<l.     Because  of  the  nerve- 
lesions  there  may  be  disturbance  of  sens;ition  (hypersesthesia  or  autes- 
thesia)  or  impairment  of  motion  of  the  iiand  and  fingers. 

When  the  joint-wound  is  due  to  pistol  shot  the  |n-obabilities  are  very 
great  that  the  limb  can  be  saved,  and  that  with. considerable,  it  may  be 
quite  perfect,  after-usefulness ;  and  the  same  will  doubtless  prove  to  be 
largely  true  in  the  injuries  caused  by  the  new  missile,  except  those 
received  within  the  explosive  zone.  Associated  wounds  of  the  lu'aehial 
artery  and  the  median  and  museulo-spiral  nerves  have  long  been  iield  to 
necessitate  am])utation,  but  by  ligation  of  tiie  vessel  and  rigid  antisei)tic 
treatment  it  will  doubtless  be  possible  at  times  to  save  the  arm,  though 
its  functional  value  will  be  much  impaired.  In  the  crushings  Ijy  large 
shot  and  in  the  extensi\e  lacerations  produced  by  small  shot  at  short  range 
ani|)titation  will  ordinarily  have  to  be  performed.  Occasionally  the  ope- 
ration may  be  done  at  the  joint,  Init  commonly  the  damage  to  the  soft 
parts  will  be  such  as  to  necessitate  removal  higiier  up.  Heretofore  the 
mortality-rate  of  such  operations  has  been  greater  than  that  of  amputa- 
tion through  the  middle  of  the  arm  or  above  that  level  (20.70  per  cent,  as 
agiiinst  12.30  per  cent.,  or  13.(57  per  cent,  as  given  by  Otis),  but  prob- 
ably not  only  the  actual  but  the  relative  death-rate  will  be  nuich  lowered 
under  antiseptic  treatment,  ])articularly  so  if,  as  has  been  thought,  the 
greater  mortality  of  operations  in  tiie  lower  tliird  has  been  due  to  unno- 
ticed fissiu'es  extending  above  the  level  at  which  the  removal  is  made, 
through  which  fissures  pyogenic  organisms  have  entered  the  bone. 

In  tiie  great  majority  of  cases  these  wounds  should  be  treated  expect- 
antly, by  immol>ilization,  and  with  the  most  thorough  antisepsis. 

The  result  may  l)e  expected  to  be  not  only  better  than  that  following 
operative  interference-,  but  mucii  better  than  that  heretofore  secured — 
fewer  ankyloses,  less  impairment  of  the  motions  of  the  hand  and  fingers,  and 
much  more  perfect  use  of  the  preserved  joint.  It  is  not  likely  that  under 
the  present  method  of  dressing  from  first  to  last  a  future  investigator  will 
find,  as  did  Dominick  after  the  Franco-(Tennan  War,  that  in  163  cases 
there  was  complete  ankylosis  in  82.8  ])er  cent.,  incomplete  in  11  per 
cent.,  and  free  mobility  in  l)ut  0.2  per  cent. 

Aminitation,  as  has  already  been  stated,  is  indicated  only  when  there 
has  been  great  injury  to  both  bones  and  soft  parts.     Excision,  which 


474  GUNSHOT   WOUNDS. 

done  for  disease  is  liifjlily  successful,  and  wliicli  was  extensively  tried 
in  the  late  wars  in  our  CDuntrv  and  in  Eurojie,  is  not  now  regarded 
with  favor  hv  the  irreat  majority  of  surgeons.  Its  mortality-rate  in  ])re- 
asej)tic  days  Mas  from  20  to  25  per  cent.,  and  that  whether  the  ui)era- 
tion  was  partial  or  complete,  and  the  end-result  was  not  good  in  about 
75  per  cent,  of  those  who  recovered.  Gurlt's  statistics  show  that  in  44.3 
per  cent,  there  was  ankylosis  of  the  elbow,  and  in  o(J.2  j)er  cent,  altnormal 
mobility,  and  in  only  32  per  cent,  was  the  usefulness  of  the  hand  pre- 
served. Of  course  much  of  the  after-ditliculty  was  due  to  inflannnations 
and  snp[)urations  which  can  now  be  prevented,  and  further  experience 
may  show  that  excision  is  a  better  operation  than  it  is  to-day  believed 
to  be. 

Wrist. — This  injury,  which  is  not  very  connuon  and  is  often  in  asso- 
ciation with  lesion  of  the  lower  ends  of  the  radius  and  ulna  above  and  of 
the  second  row  of  the  carjnis  and  the  metacarpus  below,  is  more  frequently 
met  with  on  the  left  than  on  the  right  side.  When  the  bullet  passes 
antero-posteriorly,  much  less  damage  is  done  than  when  its  course  is 
from  side  to  side.  Neither  the  pistol  ball  nor  the  small-calibred  bullet 
of  to-day  is  likely  to  do  anything  like  as  much  harm  as  was  done  by  the 
old  .45,  .50,  or  .55  calibre  soft-lead  bullet,  except  when  fired  at  close 
range.  Associated  injury  of  tendons,  l>ursw,  nerves,  and  vessels,  one  or 
all,  is  frequent,  and  much  of  the  gravity  of  the  lesion  in  former  times  was 
due  to  suppurative  inflammation  of  the  tendon-sheaths  and  of  the  palmar 
bursa,  by  contiguity  led  up  along  the  fascial  planes  of  the  forearm.  To 
such  septic  inflammations  and  those  of  the  damaged  bones  was  due  almost 
entirely  the  genei'al  mortality-rate  of  these  wrist-wounds — during  our  late 
war  12.9  per  cent.,  and  in  the  Franco-(ierman  War  12  per  cent. 

The  prognosis,  therefore,  at  the  present  day  must  be  greatly  more 
favorable ;  it  certainly  is  so  in  the  wounds  of  the  joint  that  commonly 
come  under  care  in  private  practice. 

The  treatment  should  t)e  expectant,  except  when  the  laceration  is  so 
very  extensive  as  to  necessitate  primary  anq)utation.  Formal  excision 
should  not  be  done  ;  the  mortality  attending  it  during  our  war  was  more 
than  twice  that  after  conservative  treatment  (15.6  against  7.67  per  cent.); 
in  only  3  out  of  72  cases  were  the  results  in  "  any  way  good  "  (Gurlt) ; 
of  16  German  patients,  but  one  had  a  good  arm  and  hand  ;  eight  times  the 
]>arts  were  but  tolerably  useful ;  six  times  they  were  bad  ;  and  once  the 
forearm  and  hand  were  worse  than  useless:  well  might  (lUrlt  say  that 
the  results  were  "  very  unfavorable."  Removal  of  the  lower  cn<l  of 
either  radius  or  nlna  alone  was  almost  certain  to  be  followed  by  lateral 
deflection  of  the  hand  even  to  a  right  angle.  The  ankylosis,  deform- 
ities, and  impaired  finger-movements  that  so  generally  followed  con- 
servative treatment  als(j  in  the  past  will  do  so  in  much  less  degree  in 
any  future  war,  when  wounds  will  be  rendered  and  kejit  in  some  measure 
at  least  free  from  infection,  immobilization  of  the  forearm  and  hand 
secured,  and  methodical   movements  of  the  fingers  duly  made. 

Hip. — Wounds  of  this  joint  are  of  infrequent  occurrence,  being  but 
from  one  and  a  half  to  three  in  the  thousand  of  all  gunshot  injuries,  yet 
are  of  extreme  imjiortance,  "pre-eminentlv  hazardous  to  life,  obscure  in 
diagnosis,  and  difficult  in  treatment  "  (Huntington). 

In  about  one-eighth  of  the  cases  in  our  war  the  lesion  was  periarticular 


WOUyDS  OF  SPECIAL  JOISTS.  47-") 

(49-386),  the  capsule,  however,  being  probably  opened  in  a  considerable 
proportion  of  them.  The  diagnosis  of  sucli  injuries  often  remains  uncer- 
tain, and  prognosis  is  grave  or  (jtherwise  according  as  there  are  or  are  not 
serious  complicating  wounds  of  vessels,  nerves,  or  the  abdominal  organs, 
or  (and  this  is  one  of  their  chief  dangers)  as  septic  joint-intlaniniation  is 
or  is  not  secondarily  developed.  Of  the  49  cases  in  our  war,  21  proved 
fatal.  Uncomplicated,  their  treatment  is  that  of  flesh-wounds  in  general, 
excejit  in  those  cases  in  which  a  trochanter  is  guttered  or  perforated 
withdut  Assuring  into  the  neck,  and  then  it  is  that  of  ordinary  bonc- 
injiiries  of  like  character. 

An  articular  lesion  may  be  of  the  neck,  the  head  of  the  femur,  or  of 
the  acetabulum,  or  of  two  or  all  combined.  That  it  has  occurred  when 
the  vulnerating  body  is  a  bullet  whicii  has  made  the  usual  narrow  track — 
and  this  is  the  more  common  condition — may  be  indicated  by  free  dis- 
charge of  bloody  synovia  or  by  the  usual  symptoms  of  fracture  ;  but  in 
a  large  number  of  cases  its  determination  must  rest  on  the  line  of  direc- 
tion of  the  ball,  the  bone-fragments  being  mainly  held  in  place,  and  those 
which  are  detached  being  at  such  depth  in  and  around  the  capsule  as  not 
to  be  discovered  except  upon  free  opening  up  of  the  joint.  Even  though 
extensive  Assuring  be  present,  the  wounded  man  may  yet  be  able  to  stand 
upon  the  limb  and  walk,  occasionally  for  several  days.  Twelve  such 
cases  are  reported  liy  Deininger.  Tlie  results  in  all  past  wars  have  been 
exceedingly  bad  :  in  the  French  arm}-  in  the  Crimea  the  mortality-rate 
was  93^  \)QT  cent. ;  in  our  war,  84.7  per  cent. ;  in  the  German  army  in 
1870-71,  77.9  per  cent.  In  civil  life  the  injury  is  very  rare  and  often 
associated  with  grave  vessel  or  visceral  wound  ;  the  chances  of  recovery, 
when  it  occurs,  are  of  course  better  than  in  military  practice,  but  still 
far  from  being  good. 

The  fatality  in  cases  ending  quickly  is  due  to  shock,  M'hicli  is  great, 
to  hemorrhage  from  large  vessels  in  the  vicinity  of  the  joint,  or  to  asso- 
ciated abdominal  wounds ;  in  those  living  some  days  it  is  due  almost 
entirely  to  septic  infection.  The  lethal  influence  of  shock  will  be  much 
as  it  has  been  ;  that  of  hemorrhage  may  lie  expected  to  be  somewliat 
lessened,  as  ligations  may  l)e  done  with  much  less  danger  of  after-sup- 
purations and  secondary  hemorrhage ;  that  of  wound-infection  will  be 
removed  in  great  measure  in  civil,  in  considerable  measure  certainly  in 
army  ))racticc. 

Treatment  is,  as  in  other  joint^lesions,  conservative  or  operative. 
Much  more  largely  than  heretnfire  will  it  be  by  expectancy.  Never 
again,  in  all  probability,  will  its  mortality-rate  be  anything  like  so 
frightful  as  in  our  war  (98.87  per  cent.),  when  those  who  lived  Ijcyond 
tiie  first  few  days  with  scarcely  an  exception  died  of  suppurative  inflam- 
mation of  the  joint  and  the  structures  around  ;  nor  that  of  the  war  of 
1870  (75  per  cent.,  Deininger;  71.59  per  cent.,  Langenbeck).  Gunshot 
groovings  and  perforations  antiseptically  treated,  well  immobilized,  with 
the  parts  maintained  in  ])roper  position  by  extension,  siiould  unite  mudi 
as  do  tlie  ordinary  fractures  of  the  liip  ;  and  there  is  every  reason  to 
believe  that  they  will.  If  re(piirc(l,  arthrotomy  for  the  removal  of 
loose  fragments  or  the  disinfection  and  drainage  of  the  joint,  or  late 
formal  resection,  may  be  done  with  a  fair  prospect  of  a  favorable  ter- 
mination of  the  case.     Primary  exsection  rarely  need  be  performed,  and 


47(1  GUNSHOT   WOUNDS. 

in  tlic  ahscnce  of  septic  inflammation  and  suppuration  tliere  will  he  no 
.sucli  danger  in  operating  after  a  f(.'\v  days  or  weeks  as  there  was  for- 
merly, when  the  so-called  intermediary  and  secondary  resections  were 
done.'  In  a  word,  though  probably  excisicjn,  which  was  first  done  by 
Oppenheim  in  1829,  will  seldom  be  required,  its  I'esults  will  be  much 
better,  and  quite  a  considerable  proportion  of  those  operated  upon  will 
be  able,  as  a  very  few  heretofore  have  been,  to  stand  and  walh  with 
much  freedom  and  but  little  fatigue.  The  oj)eration  may  be  done  either 
through  one  of  the  ordinary  posterior  incisions  or  through  the  anterior 
incision  of  Hueter,  according  to  the  i)art  of  the  bone  most  extensively 
damaged. 

Amputation,  originally  performed  by  Larrey  in  179o,  will  be  re- 
served for  those  eases  in  which  the  destruction  of  the  l)one  and  the  adja- 
cent soft  parts  has  been  ver'y  great,  those  in  which  the  femoral  vessels 
(arteries  and  veins)  liav^e  been  damaged,  and  as  a  late  operation  when  the 
condition  of  the  parts  that  have  been  treated  expectantly  or  even  by 
excision  is  such  as  to  make  it  evident  that  the  limb  cannot  be  saved,  or 
if  saved  that  it  will  be  of  little  value.  As  has  been  stated  of  the  other 
methods  of  treatment,  the  adoption  of  this  will  in  the  future  be  followed 
l)y  better  results  than  in  the  jiast,  and  for  the  same  reasons,  though 
shock  and  hemorrhage  must  still  exercise  a  very  grave  influence  ;  and  it 
was  chiefly  to  these  that  we  must  attribute  the  death  within  twelve 
hours  of  16  out  of  the  22  cases  that  died  after  primary  amputations 
done  during  our  war.  Hemorrhage  at  the  time  of  the  ojieration  may 
now  be  very  thoroughly  controlled  by  the  use  of  long  ])ins  (as  in  the 
method  of  Wyeth),  or,  if  the  character  of  the  wound  foi'bids  their  use, 
by  amputating  through  the  thigh  and  later  extracting  the  bone  above 
after  a  method  like  that  of  Furneaux  Jordan.  Historically,  it  is  a 
matter  of  much  interest  to  know  that  the  mortality-rate  of  all  the 
amputations  at  the  hi])-ioint  during  our  late  war,  66  in  numlier,  was 
83.3  per  cent. — 88  primary,  100  intermediary,  55.5  secondary;  in  the 
war  of  1870-71,  100  per  cent;  in  all  the  wars  of  the  century  up  to 
the  close  of  the  Franco-German  War,  as  published  in  the  Medical  and 
Surgical  History  of  the  War  of  the  Bebellion  (250  cases),  89.1  per  cent. 

Knee. — The  exposed  position  of  this  joint  renders  it  very  liable 
to  be  injured,  the  lesion  being  articular  in  about  nine-tenths  of  the 
cases. 

When  periarticular,  it  is  most  often  behind  the  joint  in  the  popliteal 
space,  and,  aside  from  septic  complications,  is  dangerous  only  in  pro- 
portion to  the  injury  done  the  vessels  and  nerves,  ^^'ounded  vessels 
being  tied  and  antiseptic  dressings  applied,  with  immobilization  of  the 
limb,  recovery  may  be  expected  to  follow,  the  leg  and  foot,  however, 
not  seldom  being  seriously  damaged  functionally  on  account  of  nerve- 
lesion.  Under  the  old  method  of  treatment  secondary  hemorrhage 
often  occurred,  and  at  times  gangrene  from  thrombosis  of  the  contused 
popliteal  artery  or  vein.  Removal  of  the  limb  can  be  required  only 
when  the  injury  to  the  parts  has  been  very  extensive.     Of  the  351  cases 

'  In  our  late  war  the  niortalitv-nite  of  primary  excision  was  9ti.9  per  cent.,  inter- 
mediary 90.9,  secondary  72.7  ;  Langenbeck's  statistics  slinw  100  jier  cent,  of  deatlis  after 
primary  and  intermediary,  and  75  per  cent,  after  secondary  operations,  and  Gurlt's,  100 
per  cent,  after  primary,  85.7  after  intermediary,  and  93.7  after  secondary. 


WOUNDS  OF  SPECIAL  JOINTS  in 

observed  in  our  war,  27.9  per  cent,  died,  the  mortality-rate  of  the  313 
cases  treated  conservatively  being  22  per  cent. 

Of  the  articular  wounds  a  few  are  without  bone-injury,  the  shot 
passing  tlirough  the  U})per  synovial  pouch  or  across  the  front  of  the 
joint  in  flexion.  A  few  (about  1  per  cent,  during  our  war)  are  of  con- 
tusion only,  but  the  great  majority  are  of  fracture,  the  patella  alone 
being  damaged  in  somewhat  less  than  10  per  cent.  The  ball  may  come 
into  the  joint  through  the  femur  or  tibia,  or  the  bone-lesions  may  be 
secondary  to  the  piercing  of  the  capsuU'.  The  cavity  may  be  opened  at 
once  by  cracks  running  from  the  track  of  a  ball  that  has  penetrated  or 
more  often  perforated  the  condyle,  or  secondarily  because  of  septic  Ijone- 
inflammation.  If  the  bullet  has  passed  through  the  bone  into  the  joint, 
tiie  incrusting  cartilage  may  be  largely  destroyed  or  only  split  open,  the 
slit-like  wound  rapidly  closing. 

All  the  characteristic  symptoms  of  joint-injury  are  here  manifested 
in  high  degree,  and  in  pre-aseptic  days  septic  intlanunations  (osteomye- 
litis, arthritis,  periarthritis)  were  almost  alisolutely  certain  to  be  rapidly 
developed.  Associated  wounds  of  the  popliteal  vessels  and  nerves  are 
at  times  present. 

Prior  to  1876  the  prognosis  of  these  knee-fractures  was  very  grave, 
death  occurring  in  more  than  two-tliirds  of  the  cases.  In  the  Crimean 
M'ar,  according  to  LoTigmore,  not  a  man  recovered  except  after  ampu- 
tation, and  niue-tenths  of  those  operated  upon  died.  In  our  war  the 
mortality-rate  of  the  3355  cases  reported  was  53.65  per  cent.,  and  of 
these  cases  28.3  were  of  injury  of  the  patella  only.  But,  beginning 
with  the  cases  treated  l>y  v.  Bergmann  and  Reyher,  the  results  of  the 
comparatively  few  injuries  observed  in  recent  years  have  been  greatly 
more  encouraging.  Protected  from  infection,  there  is  no  good  reason 
why  the  mortality-rate  shoidd  not  be  very  much  lowered,  especially  in 
the  injuries  observed  in  civil  practice,  which,  comparatively,  are  not 
severe. 

As  with  the  other  joints,  so  here :  three  methods  of  treatment  are 
before  the  surgeon  from  which  to  choose — exjiectancy,  amputation, 
excision  ;  and,  as  is  true  of  the  other  joints,  the  knee  may  now  in  the 
great  majority  of  cases  be  treated  most  satisfactorily  liy  the  first.  Selec- 
tion of  method  is  not  to  be  determined  by  consideration  of  statistics. 
It  matters  little  that  under  conservative  treatment  the  American  mor- 
tality was  60.6  per  cent. ;  that  of  1866,  43.5  ;  tliat  of  1870-71,  48.1 
(German),  50.7  (French);  that  of  1877,  28.3;  that  after  ani]>utation 
the  death-rate  in  1861-65  was  53.6  per  cent,  when  the  removal  was 
through  the  lower  third  of  the  femur,  56.6  when  at  the  knee-joint;  that 
excision  terminated  fatally  with  us  in  SI. 4  ])er  t'cut.  of  the  cases,  in 
1864  in  85.7  percent.,  in"lS66  in  86.6,  in  1S70-71  in  80,  in  1876-77 
in  100  per  cent.  These  figures  have  now  but  an  historic  value;  the 
conditions  under  which  treatment  by  any  method  is  carried  out  ai'e 
materially  changed. 

When  the  injury  is  other  tlian  a  very  extensive  one  conservatism 
should  be  employed  ;  when  the  liml)  evidently  cannot  be  saved  it  sh;)uld 
be  taken  off.  What  is  to  be  the  place  of  excision  in  the  future  remains 
to  be  determined.  The  operation  in  civil  life  for  pathological  conditions 
and  f  >r  ordinary  traumatisms  (in  the  few  cases  in  which  it  has  been 


478  GUNSHOT   WOUNDS. 

eni])loy('(l)  has  been  so  free  from  risk  to  life,  and  so  satisfactory  in  its 
end-result,  tliat  it  is  quite  prohalile  that  where  the  surroundings  are 
favoral)le  and  the  patient  need  not  he  moved,  excision  will  at  times, 
perhaps  often,  Ije  done.  After  this  operation,  and  especially  in  the  cases 
treated  expectantly,  the  functional  value  of  the  part  will  hereafter  be 
much  greater  tlian  heretofore,  since  the  ankyloses  will  be  fewer  and  the 
periarticular  thickenings  and  adhesions  decidedly  less.  During  the 
course  of  treatment  constant  care  nnist  be  taken  to  prevent,  or  at  least 
to  limit  as  nuich  as  possil)le,  angular  deformity. 

Ankle. — ^\'ounds  of  the  foot  and  of  the  lower  part  of  the  leg 
involving  the  ankle-joint  have  been  often  observed  in  time  of  war, 
this  articulation  being  the  fourth  of  the  six  larger  joints  in  order  of 
frequency  of  damage,  and  occasionally,  though  rarely,  such  lesions  are 
met  with  in  civil  life. 

The  periarticular  injuries,  which  constitute  but  a  very  small  minority 
of  the  cases  coming  under  care,  are  of  more  than  ordinary  interest 
because  of  the  frequency  of  tendon-lesions,  with  their  associated  danger 
of  suppurations  ruiniing  up  along  their  sheaths,  and  of  the  later  restric- 
tion of  movements  of  the  ankle  and  foot.  Division  of  the  anterior  or 
posterior  tibial  artery  necessitates  ligation. 

Unless  produced  at  short  range,  wounds  of  the  bones  of  the  joint 
by  pistol  balls  or  the  small-calibred  bullet  are  not  ordinarily  attended 
with  such  comminution  as  to  compel  operation.  Quite  often  the  frag- 
ments will  be  found  so  little  displaced  that  no  positive  evidence  of 
fracture  can  be  secured  by  either  jiressure  or  wai-rantable  movement 
of  the  foot  upon  the  leg,  and,  as  a  considerable  amount  of  synovia  may 
be  disi'harged  from  the  opened  tendon-sheaths,  the  diagnosis  must  be 
but  a  probable  one  based  upon  the  course  of  the  missile.  Even  this 
may  not  in  pistol  wounds  be  apjjarent,  because  of  lodgement  of  the 
bullet,  which  occurs  in  an  exceptionally  large  number  of  cases  as 
com parcfl  with  the  lesions  of  other  joints.  The  new  bullet  will  almost 
certainly  pass  through  and  out. 

Formerly  the  mortality-rate  was  quite  high  (2(3  per  cent,  in  our  war), 
but  antiseptically  treated  these  injuries  should  be  recovered  from  in 
very  large  measure.  Of  24  Austrians  wounded  in  Bosnia,  every  one 
got  well,  and  Nimier  reports  from  Tonkin  that  only  1  out  of  23  cases 
jn'oved  fatal,  and  that  not  from  the  injury,  but  from  an  intercurrent 
dysentery. 

Conservative  treatment  should  be  adopted  unless  amputation  is 
necessitated  by  the  great  extent  of  damage  done  the  bones  and  soft 
parts.  By  expectancy  a  very  serviceable  limb  is  generally  secured. 
Care  must  be  taken  through  the  whole  course  of  the  treatment  to  keep 
the  foot  in  proper  jjosition,  as  there  is  a  strong  tendency  to  its  over- 
extension and  to  lateral  deviation.  If  amputation  must  be  done,  it 
may  be  at  the  ankle  or  through  the  lower  part  of  the  leg,  according  to 
circumstances.  Chauvcl  and  Nimier  have  suggested  that  at  times,  \\hen 
the  destruction  has  been  of  the  parts  about  the  heel  and  the  posterior 
part  of  the  sole,  an  osteoplastic  resection  (the  Wladimirotf-Mikulicz 
operation)  might  well  take  the  place  of  an  amjiutation. 

Exsection  of  the  ankle  yielded  very  unsatisfactory  results  in  both 
our  own  war  and  the  Franco-German,  and  its  death-rate  was  high  (35.5 


WOUNDS  OF  REGIONS.  47!) 

per  ceut.  with  us,  nearly  three  thiies  that  of  ankle-jdint  aniputatiuns, 
13.43  per  cent.,  and  nearly  10  per  cent,  higher  than  that  of  leg  ampu- 
tations in  general,  26.02  per  cent.).  It  is  doubtful  if  it  ever  will  be 
much  favored,  as  most  if  nut  all  of  its  advantages  can  be  secured  by 
an  intormal  removal  of  fragments  if  any  active  interference  is  re<(uirc(l, 
and  tills  will  not  often  be  tiie  ease.  As  with  joint-wounds  generally,  liy 
a  strict  antiseptic  treatment  and  firm  immobilization  not  only  will  life 
be  saved,  but  a  serviceable  limb  secured — far  better,  as  a  rule,  than  any 
artificial  leg.  Occasionally,  of  course,  here  as  in  other  articulations 
there  may  be  such  persistent  bone-disease  as  will  compel  a  late  ojieration — 
sequestrotomy,  excision,  or  amputation  ;  but  just  in  ])roportion  as  an 
aseptic  state  of  the  wound  is  secured  and  maintained  will  the  likelihood 
of  this  be  diminished. 

Wounds  of  Regions. 

Head. — Injuries  of  the  head  are  among  the  more  common  wounds 
met  with  in  war,  and  of  not  infrequent  occurrence  in  civil  life.  They 
are  either  of  the  scalp  or  of  the  cranium — many  more  of  the  former  than 
of  the  latter  as  they  come  under  treatment  (7739  against  4350  in  our  late 
war).  But  it  must  be  remembered  that  one-half  of  these  head-lesions 
have  proved  fatal  on  the  field,  and  it  may  reasonably  be  expected  that  a 
much  larger  number  will  be  killed  by  the  new  bullet,  because  of  its 
greatly  increased  velocity. 

The  scalp-wounds  are  either  contusions  (rarely  met  with),  lacerations, 
perforations,  or  penetrations  with  lodgement  of  the  ball.  Injuries  of  the 
latter  class  have  been  but  seldom  seen  in  military  service,  and  are  not 
likely  to  be  produced  by  the  modern  missile — never  except  when  it  is 
very  near  the  end  of  its  flight.  Pistol  lialls,  especially  those  of  small 
calibre,  are  often  buried  in  the  tissues,  frecpiently  nuich  flattened.  Com- 
monly they  can  be  easily  felt  or  their  situation  determined  by  ])robing. 
When  in  the  temporal  muscle  their  location  may  be  indicated  only  by 
pain  upon  movement  of  the  lower  jaw  and  upon  pressure  above  the 
zygoma.  Laceration  of  a  temporal  or  occipital  artery  may  give  rise  to 
considerable  hemorrhage  and,  as  is  the  case  in  other  traumatisms  of  the 
scalp,  the  development  of  a  condition  simulating  depressed  fracture. 
Such  blood-accumulation,  if  not  rajiidly  absorbed,  should  be  aspirated  or 
cut  down  upon  and  washed  out  with  an  antiseptic  solution.  Properly 
treated,  these  injuries  may  be  expected  to  be  readily  recovered  from, 
though  heretofore  the  mortality-rate  has  been  from  6  per  cent,  to  nearly 
30  \)er  cent,  in  different  wars,  the  fatality  being  consequent  upon  septic 
disease  of  one  form  or  another.  The  ordinary  antiseptic  treatment 
should  be  thoroughly  carried  out,  the  l)ullet  if  lodged  being  removed 
when  its  location  has  been  determined. 

The  cranial  lesions  are  those  of  either  contusion,  penetration,  or  jier- 
foration.  Contusions,  which  were  about  7.5  per  cent,  of  these  lesions  as 
met  with  during  our  war,  are  produced  by  the  glancing  imjxict  of  a 
rapidly-moving  missile  or  the  direct  blow  of  a  shot  having  but  little 
momentum.  They  jirobably  will  not  be  caused  by  the  new  bullet,  as 
almost  certaiidy  it  will  fracture  the  bone  when  it  strikes  it.  As  is  the 
case  with  like  injuries  of  other  bones,  the  damage  done  may  be  slight. 


480 


GUNfSHOT   WOUNDS. 


giviiiij  rise  to  no  syniptonis  ;  or  iiiorc  severe,  causing  limited  extravasa- 
tions, after  a  time  absorbed,  or  superiicial  necrosis  and  exfoliation  ;  or 
sutttciently  great  to  cause  a  sej)aration  of  the  outer  table  over  a  small 
surface  ;  or,  but  very  rarely,  to  destroy  the  vitality  of  the  entire  thickness 
of  the  bone.  The  inner  table  may  he  fractured,  with  more  or  less  dis- 
placement of  fragments  toward  the  interior  of  the  skull,  but  this  is  of 
infrequent  occurrence  (Fig.  34). 


Gunshot  contusion  of  cranium,  witlx  fracture  of  internal  table,  exterior  and  interior  view  (A.  M. 

M.,  Spec.  2313). 

The  wound  becoming  infected,  inflammation  of  the  diploic  veins  is 
very  likely  to  follow,  with  resulting  pvieniia  with  ab.sce.sses  in  the  lung 
or  liver,  or  a  sujjpurative  meningitis.  Ivarcly  is  the  "  putfy  tumor"  of 
Pott  present. 

It  is  to  such  infection  that  the  fatality  of  the.se  contused  injuries  has 
been  chiefly  due,  the  percentage  of  which  reached  16.8  in  our  war,  and 
the  prevention  of  such  septic  conditions  will  ensure  recovery  in  the  great 
majority  of  the  cases — in  all,  we  may  expect,  except  tho.sc  in  which 
fragments  of  the  inner  table  are  driven  down  or  the  associated  brain- 
concussion,  laceration,  and  hemorrhage  are  of  themselves  mortal.  The 
wound  must  be  thoroughly  cleansed,  an  anti.septic  dressing  applied, 
and  the  patient  ke])t  (juiet.  If  eonstitntii^nal  sym]itoms  of  decided 
severity  arise,  indicating  infective  inflammation  of  bone  or  meninges, 
the  contused  area  should  be  freely  exj)osed  and  trephining  done. 
The  operation  as  now  conducted  will  not  add  to  the  gravity  of  the 
case,  whatever  may  have  been  true  of  it  formerly,  and  it  will  make 
it  possible  to  remove  any  detached  pieces  of  the  internal  table,  to  disin- 
fect, and  to  secure  drainage.  Sometimes — and,  iinfiDrtiinatcly,  not  so 
very  rarely — no  symjitoms  of  moment  are  jiresent  for  many  days,  when 
suddenly  violent  headache  is  experienced,  followed  by  eonvulsions,  coma, 
and  death  from  cerebral  abscess.  For  three  months  or  more,  the 
huntlred-day   period  of   Pare,   the    patient  is  exposed    to    this  danger. 


WOUNDS  OF  REGIONS.  481 

Except  in  the  mildest  cases,  such  as  may  readily  escape  detection,  and 
frequently  do  so,  there  is  usually,  after  recovery  from  the  immediate 
effects  of  the  wound,  and  it  may  be  for  a  long  time,  more  or  less  head- 
ache, often  associated  with  dizziness,  intolerance  of  light  and  sound, 
nausea,  and  vomiting.  Epilejjsy,  paralysis,  and  mental  irritability  have 
in  many  cases  been  produced,  as  in  similar  contusions  from  violence 
other  than  gunshot.  The  prognosis,  therefore,  is  more  grave  than  the 
mortality-rate  would  indicate.  Occasionally,  though  not  often,  bone- 
atroi)hy  follows,  exceedingly  seldom  hypertrophy. 

Tiie  fractures  produced  by  gunshot  are  graver  lesions  than  those  con- 
sequent upon  other  traumatisms,  because  of  the  greater  intensity  of  the 
vulnerating  force.  Association  of  brain-injury  is  more  constant  and  the 
visceral  damage  much  more  extensive ;  and  this  whatever  the  form  of 
fracture,  which  varies  from  a  linear  break  to  a  shattering  of  several,  it 
may  be  all,  of  the  bones  of  the  skull.  This  shattering  in  bullet-injuries 
is  due,  as  in  other  fractures  of  the  head,  to  fissures  starting  from  the 
original  wounds,  to  vibrations  conducted  along  the  cranial  tiiickenings 
from  vault  to  btise  or  from  the  occipital  bone  forward,  and  also,  and  much 
more  largely,  to  the  liydraulic  pressure  set  in  action  Ijy  tiie  ball  as  it  passes 
through  the  brain.  Numerous  experiments,  beginning  with  those  of  Busch 
and  Kocher,  have  proved  beyond  question  that  there  is  such  pressure  in 
gunshot  wounds  of  semi-fluid  tissues,  that  it  is  proportionate  to  the  fluidity, 
and  that  it  is  most  strongly  manifested  in  the  brain,  whicii  is  structurally 
fitted  to  develoj)  it  and  is  confined  within  rigid  ^valls  that  will  in  the 
highest  degree  display  the  effects  of  it.  Within  the  zone  of  explosive 
action,  which  with  respect  to  tiie  head  extends,  using  the  modern  arm,  to 
600  or  800,  even  to  1000,  yards,  this  hydrodynamic  pressui'e  produces 
■\vide  destruction — so  wide  that  life  is  very  unlikely  to  be  preserved.  At 
close  range  brain  and  bone  may  be  lilown  into  fragments — less  likely  to  be 
witii  the  small-  tlian  the  large-calibred  bullet.  Wagner  of  the  Austrian 
army,  having  observed  nine  suicidal  cases  among  soldiers  in  which  death 
was  immediate,  reports  that  there  was  less  destruction  than  in  similar 
cases  previously  seen  in  which  a  large  ball  was  used ;  the  greater  part  of 
the  brain  was  intact,  there  was  less  crushing  of  bone  and  less  fissuring, 
and  the  greatest  damage  was  about  the  wound  of  exit.  Only  exception- 
ally does  tlie  hydraulic  pressure  cause  fracture  of  the  base,  and  then  in  the 
great  majority  of  the  cases  it  is  the  ethmoid  or  the  orbital  surfaces  of  the 
frontal  that  are  broken,  though  it  is  possible,  doubtless,  that  tlie  tliin  plate 
of  the  temporal  covering  the  internal  ear  may  yield.  Pistol  balls  do  not 
ordinarily  have  sufficient  momentum  to  develop  an  explosive  action,  but 
womids  jiroduced  by  tliem  at  short  range  at  times  show  splintering  of  the 
orbital  plates,  even  witii  depression  toward  the  orl)ital  cavity.  jMucIi 
interest  in  sucli  injuries  has  been  taken  since  the  death  of  President  Lin- 
coln, and  a  numbe'"  of  cases  quite  similar  to  his  have  been  put  on  record. 
At  the  autopsy  of  the  President  the  bullet,  which  had  entered  througii  the 
occipital  bone,  was  found  to  have  passed  forward  in  the  brain  and  lodged 
just  above  the  anterior  ])ortion  of  the  left  corpus  striatum.  Botii  orbital 
plates  were  comminuted,  tiie  fragments  being  forced  inward ;  tiio  dura 
mater,  however,  was  uninjured. 

The  crusliiuffs  caused  bv  larsre  shot  and  bv  sliell-fraffments,  and  the 
bullet  wounds  and  those  made  by  charges  of  small  shot  at  close  range 

Vol.  r.— 31 


482  GUNSHOT   WOUNDS. 

which  are  immediately  or  very  quickly  fatal,  have  no  practical  interest. 
It  is  in  these  cases,  iu  which  death  occurs  at  once,  that  there  is 
observed  at  times  a  stiifening  of  the  body  in  the  position  had  at  the 
moment  of  injury.  In  a  case  in  Northern  New  Ham})shire  some  years 
since,  in  which  tlie  top  of  the  head  was  blown  off'  by  a  load  of  shot 
from  a  gun  but  a  few  feet  away,  the  body  of  the  woman  was  found  sit- 
ting in  a  chair  before  the  fire  in  the  attitude  of  knitting,  with  the  needles 
which  she  had  been  using  still  held  in  her  hands.  This  "traumatic 
cataleptic  rigidity,"  though  met  witli  in  those  shot  through  the  chest 
and  abdomen,  is  usually  associated  with  cranial  injuries. 

As  in  other  bones,  there  may  be  in  the  skull  groovings,  fissurings, 
penetrations,  and  perforations.  The  groovings  are  usually  associated 
with  fissures,  which  may  affect  only  the  external  table,  but  are  gene- 
rally found  to  extend  through  the  entire  thickness  of  the  bone — always, 
perhaps,  excejit  when  it  is  "  the  supraorbital  ridge,  the  zygoma,  or  the 
mastoid  or  occipital  protuberance  that  has  Ijcen  struck,  or  the  lesion  is 
caused  by  a  sharp  fragment  of  shell "  (Otis).  In  individuals  who  have 
passed  the  age  of  puberty  the  outer  wall  of  the  frontal  sinus  may  be 
broken  in  without  accompanying  injury  of  the  inner  wall,  rarely  hap- 
pening, however,  excei)t  when  it  is  a  pistol  ball  that  is  the  vulnerating 
body,  the  shot  often  lodging  in  tlie  sinus,  from  which  it  may  be  readily 
extracted.  In  children  penetration  in  this  region  almost  certainly 
means  piercing  of  the  entire  thickness  of  the  skull  and  wound  of  the 
brain. 

When  both  tables  of  a  cranial  bone  are  broken  from  without  the 
damage  to  the  internal  is  usually  decidedly  greater  than  that  to  the  external 
table,  the  more  so  as  the  fracture  of  the  latter  is  circumscribed.  Such  injury 
is  in  accordance  with  "  Teevan's  law,"  that  fracture  always  commences 
in  the  line  of  extension,  not  that  of  compression.  When  the  vulnerat^ 
ing  force  acts  from  within,  the  splintering  is  greatest  in  the  outer  table, 
which  then  might  be  named  the  "  vitreous  "  one,  cases  of  injury  of  this 
kind  being  observed  in  suicidal  and  other  shots  through  the  mouth  and 
face,  when  the  ball,  ranging  upward,  emerges  through  the  vertex.  In 
the  exit  wound  of  a  perforation  there  will  be  noticed  the  same  excess  of 
splintering  in  the  outer  table.  The  elasticity  of  the  skull  causes  at  times 
a  return  nearly  to  its  original  position  of  a  fragment  at  first  sufficiently 
depressed  to  permit  of  the  entrance  of  a  bullet.  In  a  few  cases  pene- 
tration has  been  indicated  only  by  the  presence  of  hair  in  the  fissure, 
as  in  those  reported  by  Assistant  Surgeon  Howard  of  our  army  and 
by  Koenig  ; '  and  it  is  possible,  as  in  a  case  of  v.  Bergmann's,  that  a 
piece  of  a  projectile  may  upon  autoj>sy  be  found  in  the  brain,  and 
nothing  but  a  mere  crack  be  discovered  through  which  it  could  have 
entered. 

When  the  momentum  of  the  ball  is  not  great  the  fracture  may  be 
confined  almost  entirely  to  the  surface  struck,  slight  depression  occur- 
ring or  a  jiiece  of  the  skull  of  about  the  diameter  of  the  missile  being 
driven  in  below  the  general  level  of  the  internal  table.  Sucli  a  typical 
punctured  fracture  is  not  likely  to  be  observed  except  when  the  ball  is 
small,  fired  usually  from  a  pistol   or  a  toy  rifle.       In   cases  of  more 

^  In  a  case  reported  by  Matthew,  from  the  Crimean  War,  hair  was  found  in  a  fissure 
of  the  external  table  only. 


WOUXDS  OF  REGIONS.  483 

extensive,  but  still  not  great,  splintering  the  lesion  is  commonly  confined 
to  the  bone  struck  or  passes  but  little  beyond  it. 

Penetrating  and  perforating  wounds  are  always  very  grave  injuries. 
The  bi'aiu  is  seriously  damaged  in  those  wounds  of  this  class  not  speedily 
causing  death  from  shock  and  hemorrhage,  and  in  cases  of  penetration  there 
are  the  added  dangers  conscijut'nt  upon  the  presence  of  bone- fragments  and 
the  missile.  The  shot  may  jiass  antero-posteriorly,  laterally,  or  obliquely 
at  any  angle,  rarely  from  below  upward,  and  almost  never  directly  from 
above  downward,  except  when  produced  by  bursting  shells.  Basal  frac- 
tures, which  are  not  very  common,  are  met  with  as  continuations  of  those 
of  the  vault,  en-  in  wounds  through  the  neck  or  face,  largely  suicidal. 

That  a  cranial  fracture  (other  than  of  the  internal  table  alone,  which 
is  always  conjectural)  has  been  received  is  usually  readily  determined  by 
palpation,  by  inspection,  by  jirobing,  or  by  percussion,  which  may  give 
the  "  cracked-pot "  sound.  The  course  of  a  ball  which  has  not  passed 
through  is  often  very  uncertain,  the  missile  frequently  striking  the  oppo- 
site wall  of  the  skull  and  being  deflected,  it  may  be  at  a  large  angle.  To 
trace  it  a  probe  must  be  employed.  If  metallic  (one  made  of  aluminum 
is  far  the  best),  it  should  be  used  with  ligiit  hand,  the  head  being  inclined 
and  the  instrument  allowed  to  fall  by  its  own  weight,  since  it  is  very 
easy  to  push  it  through  the  soft  cerebral  mass.  Oftentimes  a  moderately 
firm,  elastic  one,  such  as  an  urethral  bougie,  will  be  preferable.  Always 
the  instrument  must  be  surgically  clean,  and  it  should  be  used  only  after 
careful  disinfection  of  the  external  wound  and  the  pai'ts  about.  It  is  in 
these  injuries  that  the  telephonic  probe  has  been  found  of  service.  If 
probing  shows  that  the  track  has  passed  across  the  head,  but  the  missile 
is  not  detected,  a  button  of  bone  should  be  removed  over  the  end  of  the 
canal,  and  search  be  made  back  along  the  track  from  that  side  or  for  the 
opening  of  the  new  canal  made  after  deflection.  As  in  the  memorable  case 
reported  by  Fluhrer  in  1884,  a  second  trephining  may  have  to  be  done  to 
find  the  course  of  the  shot  yet  further  deflected.  Before  any  exploration 
of  the  track  is  made  the  opposite  side  of  the  head  should  be  carefully 
examined,  as  it  may  be  that  the  ball  lies  under  the  skin  or  is  in  the  bone, 
and  is  forcing  it  out  in  such  way  as  to  be  easily  felt  or  to  be  indicated  by 
pain  on  pressure.  If  the  missile  cannot  be  found  after  reasonable  careful 
search — and  very  often  this  is  the  case — it  will  have  to  be  left.  Occa- 
sionally cerel^ral  symptoms  (paralysis  or  disturbances  of  smell,  sight,  or 
hearing)  mmII  indicate,  if  not  the  location  of  the  ball,  at  least  the  course 
that  it  has  taken  ;  but  these  symptoms  are  less  reliable  than  they  other- 
wise would  be  because  of  the  widespread  injury  of  the  brain  outside  of 
the  immediate  track  of  the  shot.  The  symptoms  of  basal  fracture  are  the 
same  as  those  of  similar  injury  from  ordinary  violence.  The  development 
of  complicating  septic  ioflanmiations  is  indicated  by  the  usual  symptoms 
of  such  affections.  As  is  the  case  in  the  ordinary  tnuunatisms  of  civil 
life,  meningeal  suppurations  are  accompanied  with  decided  elevation  of 
temperature ;  those  of  the  brain  are  not,  and  no  paralysis  occurs  in 
meningitis  at  the  base.  Fungus  cerebri,  misnamed  hernia,  has  been  met 
with  (at  least  sixty-one  times  in  our  war),  and  must  be  so  in  the  future 
in  cases  that  have  become  infected. 

The  prognosis  is  always  grave.  As  has  been  stated,  one-half  of 
those  wounded  in  action  never  come  under  care,  and  of  the  other  half 


484  GUNSHOT   WOUNDS. 

73.8  per  cent,  died  in  the  Crinioa,  4(3.1  in  1859,  59.2  in  1861-65,  51.3  in 
1870-71.  Of  perforating  and  penetrating  wounds  in  our  war,  80  and  85 
per  cent,  proved  mortal.  Balls  lodged  in  tiie  frontal  lobes  have  Ijeen  l)etter 
tolerated  tlian  those  elsewhere.  Though  much  of  tlie  fatality  heretofore 
has  been  because  of  septic  complications,  nuicli  of  it  has  l)eeii  from  causes, 
chictiy  shock  and  hemorrhage,  that  no  treatment  c((uld  have  jirevented. 
Of  the  91  pistol-shot  wounds  occurring  in  recent  years,  tabulated  by  Brad- 
ford, 51  died  (50  per  cent.),  and  of  these  39  (42.86  per  cent.)  died  within  a 
few  days,  19  (21  per  cent.)  within  a  few  hours;  that  is,  76.47  and  37.21  ])er 
cent,  of  all  who  died.  As  I'epresenting  the  probal)le  death-rate  under 
present  methods  of  treatment  and  in  a  class  of  cases  more  likely  to  recover 
than  those  in  whicli  the  damage  lias  been  done  by  an  army  bullet,  the 
pistol-ball  injuries  studied  by  Bradford  are  very  instructive.  Of  25  cases 
shot  in  the  temple,  16  (64  per  cent.)  died  ;  of  5  in  which  the  ball  entered 
through  the  ear,  all  died ;  when  the  bullet  entered  in  front  of  the  plane 
of  the  external  auditory  meatus,  59  cases  (57.7  per  cent.)  died  ;  when 
in  such  plane  or  posterior  to  it,  32  eases  (59.4  per  cent.)  died ;  the 
mortality  when  the  ball  was  removed  was  33-^-  per  cent.,  Aviien  it  was 
left,  54  per  cent.;  of  25  cases  treated  expectantly,  52  per  cent.  died. 
Lesions  of  the  anterior  part  of  the  cerebrum  were  thought  by  Guthrie 
to  be  more  grave  than  those  of  the  posterior,  and  so  Bradford  found 
them  in  a  percentage  of  1.7.  Wiiarton's  table,  however,  shows  a  much 
heavier  deatli-rate  in  Mounds  through  the  occipital  bone,  and  in  the 
Crimea  the  wounds  in  the  anterior  half  of  the  head  proved  to  be  less 
dangerous.  Wounds  from  side  to  side,  especially  those  through  the  ear 
or  very  close  to  it,  are  much  more  serious  than  antero-posterior  ones. 
In  part  this  may  be  due  to  their  being  largely  suicidal  injuries,  and 
therefore  received  at  veiy  close  range,  the  mental  condition,  moreo\"er, 
having  of  itself  in  these  wounds,  as  in  those  of  otlier  regions,  a  depressing 
influence,  decidedly  increasing  the  risk  to  life.  Lesions  of  the  cerebellum 
almost  always  prove  quickly  fatal.  Meningeal  inflammation  and  brain- 
abscesses  are  excessively  dangerous,  as  tliey  always  are,  though  by  open- 
ing up  the  inflamed  area,  if  it  is  a  limited  one,  evacuating  the  pus,  and 
securing  proper  drainage,  relief  at  times  may  be  afforded.  Fungus 
cerebri  is  very  apt  to  terminate  fatally,  esjiecially  Mhen  actively  treated ; 
82  per  cent,  of  the  cases  reported  in  1861-65  died — a  mortality-rate, 
however,  much  greater  than  in  all  probability  will  occur  hereafter.  But 
death  in  a  few  days  or  a  few  weeks  is  not  the  only  bad  result  of  these 
cranial  fractures.  Injury  of  the  optic  nerves  causes  blindness — of  the 
auditory,  deafness.  Necrosis  of  bone,  rarely  caries,  was  formerly  very 
common,  and  must  always  occur  at  times  desi)ite  the  most  rigorous  anti- 
sepsis. Cerebral  disturbances  of  all  kinds  have  been  noticed  again  and 
again,  and  in  greater  or  less  measure  are  almost  certain  to  come  on. 
Epilepsy,  paralyses,  headaches,  amnesias,  changes  in  temper  and  in 
habits,  imbecility,  insanity,  diabetes,  each  has  often  appeared,  and  tliat, 
not  seklom,  years  after  apparent  recovery.  When  the  ball  remains  in 
the  head  it  ordinarily  does  not  become  encapsulated,  but  slowly  moves 
under  the  influence  of  gravity,  and  because  of  tlie  pressure  exerted  by 
it  and  the  organic  changes  induced  by  its  irritating  action  the  almost 
absolute  certainty  is  that  some  form  of  brain-trouble  will  at  some  time 
manifest  itself. 


WOUNDS  OF  BEGIONS.  485 

The  treatment  of  these  lesions  has  reference  to  the  wound  itself  and 
to  the  complications  that  may  arise.  As  has  been  already  stated,  much 
of  the  fatality  is  consequent  upon  shock  and  primary  hemorrhage,  for  the 
relief  of  the  former  of  which,  wlien  severe,  nothing-  can  be  done,  and  but 
little  for  the  latter,  the  cases  occurring  in  military  practice  and  living 
long  enougli  to  come  under  care  being  almost  certainly  hopeless.  In  the 
wounds  of  civil  life,  if  the  bleeding  is  from  an  external  vessel,  com])res- 
sion  may  arrest  it,  but,  as  a  rule,  ligation  should  be  done ;  and  such 
should  be  the  practice  when  a  meningeal  artery  (usually  the  middle)  has 
been  injured.  It  may  doubtless  at  times  be  found  advantageous  to 
introduce  a  sterilized  gauze  plug  wlien  the  hemorrhage  is  from  the  track 
of  the  bullet  in  tlie  brain  ;  and  in  certain  exceptional  cases  periiaps, 
when  the  compression-symptoms  indicate  a  progressive  bleeding,  ligation 
of  the  carotid  may  be  of  service. 

The  wound  being  from  pistol  shot,  the  scalp  should  be  shaved,  the 
damaged  area  antiseptically  cleaned,  and  if  penetration  has  occurred  a 
button  of  bone  including  the  entrance  wound  removed  by  trephining ;  in 
other  words,  the  injury  should  be  treated  as  though  it  was  an  ordinary 
punctured  fracture  of  the  skull.  Removal  of  the  bone  does  not  add  to 
the  gravity  of  the  lesion,  and  permits  of  the  taking  away  of  any  frag- 
ments that  may  be  present  at  the  orifice  and  the  more  ready  examination 
of  the  track  within.  Careful  search  for  tlie  ball  and  deejily  located  bone- 
splinters  should  then  be  made,  and  if  found  they  should  be  removed  with 
a  forceps  no  larger-  than  is  absolutely  recpiired.  But  in  searcliing  and 
extracting  care  must  be  taken  to  do  as  little  violence  as  possible  to  the 
brain  already  seriously  injured.  When  the  foreign  bodies  have  been 
taken  out,  or  if  the  bullet  is  not  found,  or  if  found  is  at  such  dejith  as 
to  make  it  unwise  to  attempt  its  removal,  the  blood-clots  and  devitalized 
tissue  in  the  canal  (which  is  always  of  a  diameter  much  larger  than  that 
of  the  missile)  should  be  washed  out  very  carefully  or  scraped  away,  a 
drainage-tube  introduct'd,  and  an  antiseptic  iiead  dressing  applied.  If 
the  ball  has  passed  through  and  out,  the  exit  wound  also  may  be  tre- 
phined, or  only  its  detached  fragments  removed  to  such  extent  as  will 
allow  of  free  drainage.  Here  the  external  table  is  certainly  as  much, 
probably  more,  splintered  than  tiie  internal,  and  the  ends  of  partially 
separated  sequestra  are  pushed  away  from  the  meninges  and  brain 
instead  of  toward  them.  The  securing  of  tiiorough  drainage  is  of  the 
higiiest  importance,  for  increase  of  pressure  upon  the  brain  from  extrav- 
asated  blood  adds  much  to  the  gravity  of  the  wound.  If,  though  the 
ball  has  not  passed  out,  it  can  be  located  under  the  skin  or  in  the  bone,  it 
should  l)e  removed  and  the  injiny  thus  converted  into  a  perforating  one. 

Bradfiird's  statistics  indicate  tiiat  cases  in  which  the  lodged  ball  is 
removed  ai'ter  trejiliining  are  more  likely  to  recover  than  those  of  per- 
foration, probal)ly  l)ecause  in  the  great  majority  of  such  cases  tiie  bullet 
has  not  penetrated  deeply  and  the  brain  has  been  less  seriously  damaged. 
These  statistics  furtiier  show  that  if  the  bullet  remains  in  the  head  the 
termination  of  the  case  is  about  tlie  same  whether  any  operative  interfer- 
ence is  made  or  the  case  is  treated  expectantly. 

When  tlie  wound  is  produced  by  one  of  the  new  rifle  bullets,  if  the 
missile  enters  tiie  cranial  cavity  it  will,  except  at  an  extreme  range,  pass 
through,  and  there  will  be  no  occasion  for  searching  for  it  or  extracting  it. 


486  GUNSHOT  WOUyoS. 

If  the  lesion  is  not  one  of  peneti'ation,  the  fracture  should  be  treated 
on  the  same  general  principles  as  apply  to  a  similar  one  due  to  an  ordinary 
trauma,  trephining  heing  done  or  fragments  Ijcing  removed  in  a  more 
informal  way  whenever  there  is  depression  or  any  decided  cunnninution. 
The  adoption  of  aseptic;  and  antiseptic  methods  of  operating  and  dress- 
ing has  greatly  changed  the  status  of  these  procedures,  which  as  now 
carried  out  do  not,  or  but  in  slight  degree,  expose  to  the  danger  of  the 
lighting  up  of  septic  inflammation,  the  development  of  which  in  former 
times  was  so  general  and  so  fatal.  Any  discovered  clot  under  the  skull 
or  under  the  dura  should  be  removed  by  irrigation  or  by  the  finger  or 
an  instrument. 

The  secondary  complications  that  may  arise  and  that  demand  treats 
ment  are  the  infective  diseases  of  the  meninges  and  brain,  with  result- 
ing ditfused  or  circumscribed  collections  of  j)ns,  and  secondary  hemor- 
rhage. Meningitis  and  nieningo-encephalitis,  which  ordinarily  come  on 
from  the  third  to  the  sixth  day,  but  are  often  deferred  for  as  many  weeks, 
and  which  present  no  features  other  than  those  met  M-ith  in  cases  of  trau- 
matisms not  produced  by  gunshot,  are  to  be  treated  in  the  same  M'ay  as 
in  the  latter,  no  treatment  commonly  being  of  much  avail.  They  are  to 
be  prevented,  if  possible,  by  the  adoption  of  a  rigidh^  antisejjtic  wound- 
treatment,  and  without  doubt  it  -will  be  possible  to  prevent  them  in  a 
considerable  proportion  of  the  cases  in  civil  life. 

When  the  sympttmis  present  indicate  the  formation  of  cerebral 
abscess — and  these,  unfortunately,  do  not  ordinarily  show  themselves 
until  rupture  has  taken  place  into  a  lateral  ventricle  or  the  pressure 
exerted  upon  the  Ijrain  is  great — there  should  be  an  active  interference  at 
once.  Trephining,  if  necessary,  should  be  done,  and  exploration  made 
by  the  use  of  an  aseptic  director,  or,  better,  an  aspirator  needle,  or  such 
exploration  be  made  through  the  already  exj)osed  meninges  or  cortical 
substance.  There  should  be  no  hesitancy  in  carrying  the  needle  deeply, 
and,  if  required,  in  various  directions,  in  the  hope  of  finding  the  abscess, 
since  the  exploration  does  not  materially,  if  at  all,  increase  the  gravity 
of  the  situation,  and  only  in  ])romj)t  evacuation  of  tlie  pus  with  the 
securing  of  after  free  drainage  is  there  any  chance  (if  saving  life.  Occa- 
sionally such  fortunate  result  will  folloAV,  but  ordinarily  the  case  soon 
terminates  fatally. 

Secondary  hemorrhage,  almost  invariably  due  to  septic  changes  in  and 
about  the  wound,  should  be  treated  by  ligation  of  the  bleeding  vessel,  or, 
if  this  cannot  be  efi^ected,  of  the  main  trunk,  the  exti'rnal  or  common 
cai'otid.  The  mortality  attending  the  latter  operation,  formerly  great 
(68.75  per  cent,  of  the  cases  I'eported  during  the  wars  of  1861-65  and 
1870-71,  11  out  of  16  patients  dying),  should  hereafter  be  less  in  pro- 
portion as  the  fatal  result  was  directly  due  to  the  ligation,  though  ex- 
haustion from  previous  loss  of  blood,  cerebral  softening,  or  accompany- 
ing septicaemia  or  pyaemia  must  still  carry  off  many  of  those  operated 
upon.  Ligation  of  the  external  carotid  \\hen  the  bleeding  is  from  one 
of  its  branches  should  be  preferi-ed  to  that  of  the  common  ti'unk,  as  all 
recent  experience  has  shown  that  it  is  a  much  safer  operation  (as  11  to 
78),  and  at  the  same  time  more  effective  in  controlling  the  hemorrhage. 
Fungus  cerebri,  if  it  forms,  should  be  treated  expectantly  by  moderate 
compression.      Operations  on   such   mass  (ligation,   excision,   injection, 


WOUNDS  OF  EEGIOyS.  487 

cauterization)  have  not  nsually  proved  of  service,  the  mortality  attending 
tiieni  in  1861-()5  being  75. S  per  cent. 

In  the  treatment  of  basal  fractures  in  which  there  is  discharge  of 
blood  or  serum  from  the  nose,  mouth,  or  ear,  the  nasal  cavity,  the  naso- 
pharynx, and  the  external  auditory  canal  are  to  be  thoroughly  disinfected 
aud  plugged  with  sterilized  or  antiseptic  gauze. 

Face. — Wounds  of  the  face  are  perhaps  about  4  per  cent,  of  those 
received  in  action  (3.83  ])er  cent,  in  our  war),  and  are  not  seldom  met 
with  in  civil  life,  wiiere  they  are  caused  l)y  small  sliot  single  or  in  mass, 
by  pistol  balls,  and,  in  a  \'ery  few  cases,  by  pieces  of  caps  or  fragments 
of  a  gun  that  has  burst.  They  are  of  interest  chiefly  because  of  the  occa- 
sional occurrence  of  dangerous  hemorrhage,  primary  or  secondary,  or  of 
the  not  infrecpient  extensive  lacerations  that  they  produce  and  the  re- 
sulting deformity,  often  very  disfiguring.  Their  mortality-rate  has  not 
been  great — 4  to  7  per  cent,  in  different  wars,  and  this  chicily  in  the 
cases  of  fracture,  flesh  wounds  rarely  causing  death  (in  1.5  per  cent, 
only  of  the  nearly  five  thousand  (4914)  cases  tabulated  by  Otis).  Even 
this  rate  may  be  expected  to  be  much  lowered  hereafter  in  degree  pro- 
portionate to  protection  against  sepsis.  Flesli  wounds  made  by  pistol 
balls  firetl  from  a  distance  or  by  small  sliot  are  attended  with  but  little 
destruction  of  tissue,  and  are  quickly  recovered  from,  the  resulting  scar- 
rino;  beino;  usually  but  sliaht.  Occasionally  the  bullet  or  charge  of  small 
shot  seriously  damages  the  eyelids,  the  lips,  or  the  soft  pai'ts  of  the  chin, 
witii  later  cicatricial  contraction  that  may  necessitate  operative  treatment. 
Generally,  howevei",  these  graver  lesions  are  associated  with  injuries  of 
bone,  which  occur  in  about  one-third  of  the  cases.  Any  bone  may  be 
injured,  but  most  connnonly  it  is  the  inferior  maxilla,  tiie  fracture  of 
which  much  resembles,  as  respects  s])liutering,  that  of  a  long  bone.  The 
superior  maxilla  was  frequently  much  connninuted  by  the  old  large-cal- 
ibred  Ijullet,  though  tlie  fragments  were  generally  adherent;  with  the 
new  bullet  in  the  middle  ranges  much  less  splintering  may  be  expected 
to  be  produced.  Pistol  balls  crush  it  but  little,  as  a  rule,  except  when 
tiie  wcajjon  is  disciiarged  at  very  short  distance,  and  not  always  then. 
The  cavities,  orbital,  nasal,  and  oral,  are  often  penetratetl  or  perforated, 
the  shot  at  times  doing  no  direct  damage  to  the  eye  or  tongue.  Tiieir 
penetration  may  take  place  without  any  injury  to  bone.  A  bullet  may 
pass  out  through  the  mouth  or  the  anterior  nares,  not  wounding,  or  but 
slightly  wounding,  the  lijis  or  tiie  nose.  In  a  case  reported  from  the 
Franco-Gcrmau  War  a  ball  entered  through  the  anterior  nares,  struck 
the  posterior  pharyngeal  wall,  and,  reboundilig,  made  exit  through  the 
mouth.  When  tiie  missile  passes  antero-posteriorly  the  brain,  spine,  or 
great  vessels  of  the  neck  are  often  damaged,  though  not  seldom  in  suicidal 
wounds  through  the  mouth  the  brain  is  uniniured,  backward  jerking  of 
the  liead  causing  the  ball  to  take  an  upward  course  in  front  of  the  cranial 
cavity.  When  the  bullet  enters  the  lirain  through  the  orbit  or  tlie  mouth, 
death  is  almost  sure  to  follow  from  the  primary  injury  or  secondary  septic 
inflammation.  Passing  transversely,  one  or  more  of  the  larger  blood- 
vessels of  the  face  or  upper  part  of  the  neck  may  be  wounded,  and  it  is 
the  likelihood  of  the  occurrence  of  sucii  lesion  that  renders  injuries  of  the 
bodv  of  the  lower  jaw  of  grave  import.  Ijodgement  of  the  ball,  especially 
in  pistol  shots,  often  occurs,  such  lodgement  being  in  bone  or  in  one  of 


488  OUNSIIOT  wouyDS. 

the  cavities — the  frontal  sinus,  the  antrum,  the  nasal  fossa,  or  the  orl)ital 
cavity.  In  many  eases,  after  havint;'  remained  in  the  face  for  a  lonjj  time, 
the  bullet  has  heen  s])()ntaiieously  extruded,  or,  haviiiji;  uleerate<l  its  way 
into  the  nasal  fossa,  has  heen  removed.  Jn  elfeetinji;  sueh  removal  through 
the  anterior  nai-es  (it  should  not  be  pushed  baekward,  lest  it  drop  down 
the  throat)  much  diiK(udty  is  often  experienced,  particularly  so  if  the 
bullet  is  deformed.  In  such  case  the  nasal  outlet  should  be  enlarged, 
or,  better,  the  fossa  opened  throuuh  the  vestibule  of  the  mouth  by  turn- 
ing up  the  lip  after  the  metlmd  of  liouge — an  operation  which  gives  free 
and  ready  access  to  tiie  nasal  fossa  and  leaves  no  after  def()rniity. 

Striking  an  orbital  ridge,  tlie  soft  lead  ball  has  frequently  split.  The 
eyeball  is  quite  often  wounded,  in  civil  life  many  of  the  injuries  being 
caused  by  pieces  of  cap  or  small  shot.  As  a  result  the  eye,  if  not  de- 
stroyed at  once,  is  very  apt  to  be  lost  through  inflanuiiation,  and  there  is 
always  much  danger  that  sym|)athetie  ophthalmia  will  be  developed  in 
the  other  eye  if  the  injured  organ  is  not  promptly  removed.  In  a  trans- 
verse wound  of  the  face  the  Indict  may  cut  off  the  optic  nerve,  producing 
immediate  blindness,  or  so  contuse  it  or  lacerate  the  parts  immediately 
about  as  to  cause,  through  nerve-concussion  or  inflammation,  or  through 
pressure  from  a  clot,  temporary  or  permanent  loss  of  vision.  A  like  loss 
of  vision  may  be  consequent  upon  a  wound  in  the  ff)rehead,  by  some  at- 
tributed to  a  reflex  disturbance  from  a  damaged  sujtraorbital  nerve,  but 
generally  due  to  fracture  running  through  the  orbital  canal  (that  Berlin 
found  to  exist  in  every  one  of  the  thirty-four  cases  that  he  examined), 
though  it  may  be  because  of  retinal  hemorrhage  from  concussion. 

Wounds  of  the  side  of  the  face  may  involve  Steno's  duct  and  cause 
a  salivary  fistula.  Generally  such  a  fistula  may  be  expected  to  close 
spontaneously,  and  only  very  exceptionally  will  it  fail  to  do  so  under 
ordinary  treatment. 

Passing  through  the  mouth,  a  bullet  often  wounds  the  tongue,  either 
grooving  it  or  tunnelling  it.  The  resulting  swelling  of  the  organ,  which 
rapidly  comes  on,  may  reach  a  high  degree,  so  as  much  to  interfere  with 
speech,  swallowing,  and  breathing,  and  to  cause  protrusion  beyond  the 
line  of  the  teeth.  The  lesions,  however,  are  not  grave,  except  when  the 
Avounds  involve  its  under  part  and  the  lingual  artery  or  one  of  its  large 
branches  is  torn.  Not  infrequently  a  tooth  or  a  piece  of  a  tooth  is  driven 
into  the  tongue,  where  it  may  at  times  be  felt,  often  being  mistaken  for  a 
lodged  ball  until  its  removal.  In  rare  instances  the  ball  does  lodge,  and 
cases  are  on  record  in  which  it  has  remained  in  place  for  years. 

The  treatment  of  these  face-wounds  is  by  expectancy,  except  as 
vessel-lesions  necessitate  ligations.  Entirely  detached  fragments  of 
bone  are  to  be  taken  a^ay  ;  but  oidy  such,  any  adhesion,  bony  or  peri- 
osteal, being  sufficient  f)rdinarily  to  preserve  vitality.  By  manipulation 
partially  adherent  secpiestra  can  be  largely  brought  into  place,  and  if  in 
the  lower  jaw  they  cannot  be  properly  maintained  in  apposition,  they 
mav  be  wired  together.  As  is  true  in  all  the  fiice-MOunds  ordinarily 
coming  under  care,  none  of  the  soft  parts  are  to  be  cut  away,  no  matter 
how  extensively  torn  and  cruslu'd.  ^\'hcn  in  communication  A\ith  the 
mouth  or  nasal  cavity  the  Avounds  are  always  more  or  less  septic,  and 
great  care  must  be  taken  to  keep  them  as  clean  as  possible,  frequent 
irrigations  being  required.     Besides  the  ordinary  reasons  for  maintaining 


WOUNDS  OF  SEGIOXS.  489 

cleanliness,  there  is  here  the  additional  one  that  grave  distm-banees  of 
nntrition  will  be  indnced  by  the  passage  into  the  stomach  of  foul  dis- 
chai'ges  from  the  mouth. 

Primary  hemorrhage,  when  not  from  one  of  the  large  trunks,  either 
ceases  spontaneously  or  is  arrested  by  the  application  of  hot  water  or  by 
compression.  When  from  the  tongue,  it  may  l)e  so  profuse  as  to  necessi- 
tate plugging  of  the  wound  with  gauze,  its  closure  by  sutures,  the  use  of 
the  hot  iron,  or  the  ligation  of  the  lingual  or  external  carotid  arter\-.  li' 
it  is  one  of  the  main  arteries  that  has  been  torn,  the  bleeding  point  should 
be  found  if  possible,  and  a  ligatm'e  applied  above  and  below ;  and  if  this 
is  impracticable,  ligation  should  be  done  of  the  trunk  near  its  origin, 
of  the  external  carotid,  or  (but  never  when  it  can  be  avoided)  of  the 
common  carotid. 

Secondary  hemorrhage,  if  severe,  always  if  recurrent,  should  be 
treated  by  ligation,  which  frequently,  because  of  the  condition  of  the 
parts,  will  have  to  be  at  a  distance.  As  has  been  stated  before,  chemical 
styptics  should  never  be  employed  :  many  a  wounded  man  has  lost  his 
life  through  violation  of  this  rule. 

Following  destruction  of  tissue,  soft  and  hard,  cicatricial  contractions 
are  often  met  with,  atfecting  the  eyelids,  the  nose,  the  tongue,  or  the 
temporo-maxillary  articulation,  producing  deformity  and  impairing,  in 
high  degree,  it  may  be,  the  functional  action  of  the  parts.  For  the 
relief  of  these,  plastic  operations  may  have  to  be  done  upon  the  eyelids 
or  the  nose  ;  the  tongue  loosened  up ;  and  a  jaw-ankylosis  treated  Ijy 
excision  of  the  band  or  by  resection  of  the  joint,  or,  better,  the  establish- 
ment of  a  new  joint  in  front  of  the  angle,  according  as  the  ankylosis  is  false 
or  true.  ^Nluch  can  often  be  done  by  ])lastic  operations  or  by  the  applica- 
tion of  a  proper  prothetic  apparatus  when  there  has  been  an  extensive  loss 
of  substance,  the  result  generally  of  wound  by  a  cannon  shot  or  shell-frag- 
ment. It  has  long  been  known  that  recovery  takes  place  far  more  fre- 
quently than  would  naturally  be  expected  in  these  often  frightful  destruc- 
tions of  the  face.  A\'hen  tiie  superior  or  inferior  maxilla  has  been  crushed 
and  much  of  the  bone  has  ijeen  lost,  in  the  process  of  healing  considerable 
approximation  of  the  remaining  fragments  may  take  place,  ranch  lessen- 
ing the  amount  of  plastic  or  mechanical  work  that  will  have  to  be  done 
to  repair  the  damage  or  to  conceal  the  deformity. 

Neck. — About  one  in  fif^y  of  those  wounded  in  action  and  reporting 
for  treatment  has  been  found  to  be  shot  in  the  neck.  For  practical  as 
well  as  to])ographical  reasons  the  wounds  may  be  classified  as  of  the 
antero-lateral  and  of  the  jjosterior  regions,  the  line  of  separation  con- 
veniently following  the  anterior  borders  of  the  trapezius  muscles.  In 
front  of  these  borders,  except  when  very  su])erficial,  gruN'ity  attaches  to 
the  wounds  because  of  the  danger  of  a  conij)licating  injury  of  important 
vessels  or  nerves,  of  the  air-  or  food-tulies,  or  of  the  sjiine — injuries, 
however,  that  are  of  comparatively  infrecpient  occurrence,  though  often 
enough  met  with  to  make  the  mortality-rate  of  the  lesions,  taken  together, 
from  4  to  33  per  cent,  in  different  wars,  15  per  cent,  in  our  war.'  Such 
infrequency  would  be  very  surprising,  considering  the  number  and  size 

'  The  number  of  wounds  of  the  larger  vessels  in  1861-(Jo  was  235  (211  arteries,  24 
veins),  about  1  in  21  of  the  injuries  of  the  region ;  of  those  of  the  air-passages,  75,  about 
1  in  50;  and  of  the  pharynx  and  oesophagus,  29,  about  1  in  170. 


490  GUNSHOT   WOUNDS. 

of  the  vessels,  the  exposed  position  of  the  larynx  and  trachea,  and  in  less 
degree  of  the  pharynx  and  wsoj)hagiis,  and  the  size  of  the  vertebral  bodies 
and  the  spread  of  the  posterior  arches,  were  it  not  for  the  knowledge  that 
the  great  majority  of  those  wounded  in  these  parts  are  left  upon  the  field, 
having  been  over  3  per  cent,  of  those  killed  among  the  German  troops  in 
1870-71.  The  posterior  wounds  chiefly  damage  the  muscles,  though 
occasionally  the  spine  is  injured,  and  their  mortality-rate  is  very  much 
lower  than  that  of  those  located  fiu'ther  forward.  These  muscle-wounds, 
whatever  the  region,  are  of  intci'cst  only  on  account  of  the  tendency  to 
subsequent  contraction  and  the  f()rmation  of  adhesions,  which,  one  or 
both,  may  decidedly  limit  the  motions  of  the  head.  Any  produced 
torticollis  is  likely  to  improve  as  time  passes,  but  not  seldom  the  deform- 
ity has  been  a  persistent  one. 

In  the  anterior  and  antero-lateral  wounds,  if  suppurative  inflamma- 
tions arise,  there  is  a  strong  probability  that  unless  speedily  j)revented 
by  free  incision  and  thorough  drainage  it  Mill  extend  along  the  fascial 
planes  into  the  chest  or  the  axilla.  Such  inflammations,  formerly  so 
common  and  often  so  grave,  may  now  be  expected  to  be  prevented  in 
the  greater  part  of  the  cases  treated. 

Hemorrhage  as  met  with  in  military  practice  ^vill  ordinarily  be  sec- 
ondary, occasionally  intermediary,  almost  never  primary  ;  in  ci\il  jtractice, 
the  cases,  as  a  rule,  coming  under  care  comj)aratively  (|uickly,  early 
bleeding  will  be  more  often  seen.  It  is  to  be  treated  as  in  other  regions ; 
when  from  an  artery,  by  ligation  if  that  can  be  effected,  otherwise  by 
compression  ;  when  from  a  vein  other  than  the  internal  jugular,  preferably 
by  compression,  which  often  ans\vers  the  desired  purpose.  The  internal 
jugular  had  better  be  tietl,  though  its  rounds  have  been  so  luiiformly 
fatal  that  there  is  not  much  to  encourage  o]ierative  interference.  The 
difliculty  not  seldom  experienced  in  determining  what  vessels  have  been 
Avounded  or  of  getting  at  the  bleeding  point  in  the  midst  of  the  infiltrat- 
ed— it  may  be  sloughing — tissues  \vill  often  compel  ligation  at  a  distance. 
As  has  already  been  stated,  the  external  carotid  should  be  tied  for  a 
wound  of  one  of  its  branches  rather  than  the  common  trunk,  and  when 
there  is  micertainty  as  to  whether  it  is  the  external  or  the  internal  carotid 
that  has  been  damaged,  the  vessels  should  be  exposed  at  the  bifurcation, 
pressure  employed  on  them  alternately,  and  that  one  tied  the  compression 
of  which  arrests  the  bleeding.  Past  experience  proved  the  dangerous 
character  of  these  ligations  in  the  neck ;  in  the  future  there  ought  to 
be  a  lessened  death-rate  in  proportion  as  sejitic  infections  are  pre- 
vented. Of  the  76.8  per  cent,  moi-tality  after  ligation  of  the  common 
carotid  in  our  war,  and  68.75  per  cent,  among  the  Germans  in  1870- 
71,  a  decided  proportion  must  have  been  due  to  infection,  more  than 
would  ajipear  from  the  jmblished  statistics ;  and  the  same  is  true  of 
ligation  of  the  subclavian  and  its  branches  (74.5  per  cent,  in  1861-65). 

Aneurism  has  occasionally  dcvelojtcd  after  these  injuries — eleven 
times  in  1861-65,  with  9  deaths  (81.8  per  cent.),  ligation  saving  1 
case  out  of  5  (common  carotid),  and  without  ligation  1  out  of  8  surviv- 
ing, also  of  the  common  carotid.  In  a  very  few  cases  an  arterio-venous 
aneurism  has  formed,  wounds  of  the  vessels  having  established  a  com- 
munication between  the  internal  jugular  vein  and  the  c(immon,  the  in- 
ternal, or  even  the  external  carotid  artery.     Such  aneurism  has  proved 


WOUNDS  OF  BEGIOXS.  491 

but  little  dangerous  to  life,  though  cerebral  softening  has  been  known  to 
follow,  the  more  serious  effects  ordinarily  met  with  being  headaches, 
dizziness,  and  the  annoyance  of  the  persistent  bruit  and  thrill.  As 
respects  treatment,  non-interference  should  be  the  rule  of  conduct. 

Nerve-lesions,  as  might  naturally  be  expected,  are  frequent  (in  1  in 
12  of  the  neck- wounds  among  the  Germans  in  1870-71),  many  due  to 
direct  injuries  of  the  trunks,  some  to  associated  wounds  of  the  spine, 
even  contusion  of  which  may  be  followed  by  temporary  paralysis,  affect- 
ing in  rare  instances  the  four  extremities.  Wounds  of  the  larger  nerve- 
cords  produce  impairment  of  motion  and  sensation  in  the  parts  supplied, 
of  varying  degree  according  to  their  extent,  and  reflex  disturbances  may 
be  set  up  in  regions  quite  remote.  Lesion  of  the  hypt)glossal  nerve  has 
caused  motor  paralysis  and  unilateral  atrophy  of  the  tongue ;  that  of  the 
sympathetic,  contracted  pupil,  ptosis,  and  flushing  of  one  side  of  the  face  ; 
to  injury  of  the  pneuniogastric  Larrey  attributed  the  intense  thirst  which 
is  at  times  experience<l  after  wounds  of  the  oesophagus.  The  brachial 
plexus  being  wounded  by  ball  or  bone-fragment,  not  only  may  there  be 
paralyses  of  the  muscles  of  the  extremity,  with  after  contractures,  but 
trophic  changes  in  the  skin,  and  that  burning  pain  (causalgia)  which  is, 
as  Mitchell  has  declai-cd,  "  the  most  terrible  of  all  the  tortures  which  a 
nerve-wound  may  inflict."  Serious  nerve-symptoms  have  at  times  been 
consequent  upon  the  pressure  of  a  lodged  ball,  ceasing  when  the  bullet 
has  been  removed.  Several  important  nerves  may  be  injured  by  the 
same  shot,. as  in  a  case  reported  by  Stromeyer  in  which  the  phrenic,  the 
pneuniogastric,  the  middle  ganglitin  of  the  sympathetic,  and  the  desceu- 
dens  noni  were  wounded,  together  with  the  larynx  and  pharynx. 

The  superficial  position  of  the  larynx  and  trachea  exposes  them  to 
considerable  risk  of  being  wounded,  either  alone  or  together  or  in  asso- 
ciation with  injury  of  the  pharynx  or  oesophagus :  82  such  cases  were 
reported  during  our  war,  and  59  among  the  Germans  in  the  Franco- 
German  ^\'ar.  Their  mortality  is  heavy  (42.7  per  cent,  in  1861-65,  55.9 
in  1870-71),  more  so  in  tracheal  than  in  laryngeal  wounds  ;  but  much 
of  such  fatality  may  fairly  be  attributed  to  accompanying  lesions  of 
blood-vessels,  spine,  etc.  In  civil  practice  these  injuries  are  commonly 
much  less  serious,  especially  when  made  by  small  shot,  and  are  often 
contusions  or  groovings,  not  penetrations.  The  symptoms  are,  in  general, 
difficulty  of  breathing,  inqiainnent  of  voice,  spasmodic  cough,  and  more 
or  less  bloody  expectoration  and  jiain,  either  or  all  of  which  may  be  pres- 
ent when  the  air-passage  has  only  been  contused.  When  penetration 
has  occurred  there  may  be  in  addition  emphysema,  a  passage  of  air 
through  the  wound  on  expiration  causing  a  more  or  less  decided  blow- 
ing sound,  and,  if  the  jiharvnx  or  oesophagus  has  also  been  opened,  an 
escape  of  li([ui(ls,  though  this  latter  symptom  is  not  certain  proof  of 
lesion  of  the  food-tube,  since  it  may  occur  because  of  an  inactive  epi- 
glottis. If  a  laryngoscopic  examination  can  be  made,  the  internal  wound 
or  the  lodged  shot  may  at  times  be  seen.  Qilema  of  the  larynx  may 
come  on  rapidly  and  at  any  time,  or  the  trachea  be  later  compressed  by 
blood  or  exudations  outside  of  it.  Hemorrhage  into  the  air-tube  may 
cause  its  oljstruction.  So  far  as  the  wound  itself  is  concerned,  tiie  treat- 
ment is  that  of  wounds  in  general.  The  liability  to  tiie  sudden  and 
unexpected  occurrence  of  suffocation  makes   it  wise  early  to  perform 


492  GUNSHOT   WOUNDS. 

tracheotomy,  or  at  least  to  liave  tlie  jiatient  so  earefully  and  intelligently 
watehed  that  the  operation  may  be  ])roinptly  done  if  it  sliould  l)ecome 
necessary.  Very  possibly  an  early  intubation  might  often  be  done 
instead  of  a  tracheotomy,  which  latter  ojieration  in  tlie  wars  of  1861-65 
and  1870-71  was  followed  by  death  in  22  out  of  34  cases  (04.7  per 
cent.).  A  lodged  missile  should,  if  possible,  be  removed,  as  its  presence 
is  almost  certain  to  cause  trouble  sooner  or  later.  It  has  been  knoAvn  to 
ulcerate  its  way  into  the  oesophagus  and  be  discharged  at  stool.  At 
times  it  may  be  taken  out  through  the  mouth  by  an  intra-laryngeal  ope- 
ration. If  the  W(jund  does  not  prove  mortal,  there  is  aj)t  to  be  a  per- 
manent impairment  of  the  voice ;  often  because  f)f  existing  cicatricial 
stenosis  a  tube  has  had  to  be  worn  ;  necrosis  of  the  cartilages  is  not 
infrequent ;  and  aerial  fistulas  at  times  remain. 

The  pharynx  and  oesophagus  are  wounded  much  less  often  than  the 
air-passages,  but  the  mortality  of  such  wounds  is  gx'eat  (54.84  per  cent, 
in  our  war),  chiefly  because  of  other  grave  lesions  almost  necessarily  asso- 
ciated with  them,  thougji  difficulty  of  feeding  and  the  occurrence  of  food- 
pneumonia  has  not  a  little  to  do  with  it.  Unless  there  is  discharge  of 
food  through  the  external  wound,  the  diagnosis  will  largely  rest  upon  the 
determination  of  the  direction  of  the  shot,  and  often  must  remain  only 
conjectural.  INIore  or  less  associated  laryngeal  disturbance  may  be  ex- 
pected to  be  jiresent.  As  far  as  it  can  l)e  dune,  escape  of  the  fond  must 
be  prevented  by  suturing,  by  packing  the  wound  with  gauze,  or  by  the  use 
of  the  oesophageal  tube,  according  to  circmnstances,  since  the  presence  of 
food  in  the  neighboring  tissues  is  certain  to  cause  an  infective  inflamma- 
tion. In  any  case,  sn})puration  occurring,  free  exit  must  be  given  the 
pus  as  soon  as  possil^le  and  drainage  maintained.  Much  care  must  be 
taken  to  secure  to  the  jiatient  a  sufficient  quantity  of  food,  given  by  ])ref- 
erence,  as  a  rule,  through  a  tube.  Strictures  and  jiermanent  fistula  have 
resulted  in  a  small  proportion  of  the  cases  that  ha\-e  survived  the  original 
wound. 

A  wound  of  the  thyroid  gland,  if  not  com]>licated  by  tracheal  or 
oesophageal  injury,  is  of  interest  only  because  of  the  bleeding  that  occurs 
— bleeding  to  be  controlled  by  ligation  of  the  vessel  or  by  suturing,  plug- 
ging, or  cauterizing  the  wound. 

Spine. — In  these  wounds  a  vertebra  may  be  contused  ;  one  or  other 
of  its  component  parts,  body  or  posterior  arch,  fractured ;  or  the  canal 
opened,  with  associated  lesion  of  the  meninges  or  the  cord,  the  latter 
being  much  the  more  se\'cre  injury.  These  wounds  are  produced  by  mis- 
siles (bullets  or  shell-fragments)  striking  the  back,  passing  from  side  to 
side,  and  injuring  the  spine  in  its  course,  or  coming  from  in  t\x)nt,  aflect- 
ing  the  vertebra  only  after  having  wounded  the  jiarts  anterior  in  the 
neck,  chest,  or  abdomen.  It  is  to  these  last-mentioned  complications  that 
much  of  the  great  gravity  of  these  wounds  is  to  be  attributed.  As  is 
true  of  head-injuries,  this  gravity  is  in  but  slight  measure  due  to  any 
existing  bone-lesion,  being  chiefly  due  to  the  damage  done  the  cord  or 
its  coverings,  to  concussion  or  compression  from  l)lood-elot  or  jius- 
collection,  to  organic  changes  in  the  meninges  or  the  nerve-tissue,  or  to 
destruction  of  such  tissue.  Shock  is  always  great,  even  to  the  extent 
of  producing  instantaneous  death  with  following  traumatic  cataleptic 
rigidity ;  and  the  same  physical  conditions  that  favor  explosive  action 


WOUNDS  OF  REGIONS.  493 

in  the  head  are  here  present — ahimdance  of  fluid  and  a  rigid  bony 
envelope. 

The  symptoms  are  those  of  any  and  every  injury  of  the  oord,  though 
more  marked,  as  a  rule,  than  after  other  traumatisms.  They  are  im- 
pairment of  the  motions  of  the  back ;  partial  or  complete  paralvses  of 
muscles  of  the  trunk  or  extremities ;  anesthesias  and  hyperfesthesias ; 
peculiar  and  severe  pains  of  a  girdling,  gnawing,  tearing,  or  burning  cha- 
racter ;  disturbances  of  respiration,  of  circulation,  of  defecation,  of  mic- 
turition ;  neurotic  gangrenes,  often  of  rapid  development,  in  parts  pressed 
upon,  as  on  the  back,  over  the  trochanters  or  heel,  or  at  the  distal  ex- 
tremities of  the  limbs  from  defective  blood-supply,  such  as  not  seldom 
also  follow  injuries  of  the  nerve-trunks.  Sometimes,  MJien  there  has 
been  penetration  of  the  canal,  this  fact  will  be  evidenced  by  escape  of 
cerebro-spinal  fluid ;  but  this  symptom  is  by  no  means  a  constant  one, 
and  when  present  only  shows  that  the  theca  has  been  opened,  not  that 
the  medulla  has  certainly  been  damaged.  Contusions  of  the  spine  usually 
cause  but  temporary  disturbance  of  motion  or  sensation,  occasionally  a 
meningo-myelitis ;  such  inflammation,  however,  is  lighted  up  less  often 
than  after  similar  injuries  of  the  cranial  bones.  These  effects,  aside  from 
those  of  infective  character,  are,  as  a  rule,  quickly  recovered  from  with- 
out serious  after-consequences,  though  at  times  stiffness  of  the  back  or 
some  paralysis  of  an  extremity  remains,  and  in  rare  instances  necrosis 
takes  place,  as  in  a  case  reported  by  Keen,  in  which  there  was  sponta- 
neously discharged,  after  about  three  months,  "  nearly  the  entire  body  of 
the  third  cervical  vertebra,  including  the  anterior  half  of  the  transverse 
process  and  the  vertebral  foramen." 

The  fractures  that  come  under  care  are  largely  those  of  the  spinous 
and  transverse  processes.  Those  of  the  body  are  nuich  graver  lesions, 
and  that  whether  the  bone-lesion  be  one  of  groo\-ing,  of  penetration 
with  lodgement  of  the  ball,  or  of  perforation.  In  them  the  bone  is  often 
much  fissured.  The  lower  in  the  column  the  fracture,  the  less  severe  it 
is  likely  to  be,  the  mortality-rate,  as  stated  in  the  Medical  and  Surffical 
History  of  our  war,  being  70  per  cent,  in  the  cervical,  63.5  in  the  dorsal, 
and  45.5  in  the  lumbar  regions. 

Hemorrhages  outside  of  the  dura,  within  the  theca,  or  in  the  sub- 
stance of  the  medulla,  especially  the  first  two,  are  very  generally  asso- 
ciated with  spinal  injuries,  causing  severe  pain,  often  shooting  around 
the  body  and  serving  to  indicate  the  location  of  the  injury.  Such  pain, 
when  the  extravasation  is  l)ut  slight,  ordinarily  subsides  in  a  short  time, 
returning  again  temporarily  when  the  period  of  reaction  sets  in,  and 
then,  as  absorption  takes  place,  more  or  less  rapidly  passing  aM'ay,  to- 
gether with  the  paralytic  condition  produced  by  the  clot.  When  the 
clot  is  a  large  one,  its  pressure-effects  are  correspondingly  great,  and 
there  is  generally  an  associated  infective  myelitis.  Compression  of  the 
cord  is  produced  also  by  a  lodged  ball,  or,  more  often,  by  depressed  bone- 
fragments.  As  in  brain  lesions,  there  is  here  always  more  or  less  con- 
cussion of  the  medulla,  and  with  the  jarring  there  is  usually  associated 
contusion  of  greater  or  less  amount,  thougii  the  cord  is  more  protected 
by  the  "  water-bed  "  in  which  it  rests  than  is  the  brain.  Such  contusion 
with  its  associated  laceration  varies  from  that  which  is  quickly  recovered 
from,  without  any  organic  change  being  produced,  to  that  which  is  destruc- 


494  OUNSHOT   WOUNDS. 

tive  to  a  part  of  tlio  coic).  Tlip  extensive  tearings  and  crushings,  however, 
are  cliiefly  due  in  tlic  action  of  eitlier  hail,  l)one-fragment,  or  Ijotii. 

I'lie  prognosis  in  military  jjraetice  lias  always  been  very  grave,  one- 
half,  two-thirds,  three-quarters,  nine-tenths  of  the  cases  coming  under 
treatment  dying,  the  most  of  them  within  a  few  days.  In  civil  life  there 
is  more  chance  of  recovery,  the  injury,  as  a  rule,  being  less  severe  and  the 
patients  coming  sooner  under  care,  and  that  after  com])aratively  little  mov- 
ing. Wlien  the  canal  has  l)een  opened — by  j)cnetration  or  by  perforation, 
it  matters  little  wliieli — the  danger  is  very  much  greater  than  in  other 
cases  because  of  the  compression  or  laceration  of  the  medulla  ;  tlie  wound 
in  those  who  have  recovered  heretofore  liaving  been  almost  always  of  the 
sacral  or  lower  lumbar  vertebra'  ;  that  is,  below  the  end  of  the  cord 
proper.  Antisejitic  treatment  may  be  expected  to  lessen  somewhat  this 
mortality-rate,  l3ut  in  all  proljability  its  beneficial  eiiect  will  not  be  very 
great,  as  in  many  cases  it  will  be  impossible  to  secure  asepticity ;  and 
sepsis  is  l)y  no  means  the  chief  cause  of  death,  which  so  oiten  must  result 
from  shock,  hemorrhage,  or  associated  lesions  of  imjwrtant  viscera. 
When  there  has  been  no  injury  of  the  cord  or  theca,  other  than  perhaps 
a  limited  extravasation  of  blood  outside  the  sheath  or  a  slight  concussion 
of  the  medulla,  recovery  may  take  place,  and  that  with  little  after-dis- 
turljance,  organic  or  functional,  this  being  especially  true  of  wounds  of 
the  processes,  particularl)-  the  spinous.  Kareh',  however,  is  the  wounded 
man  so  fortunate.  Almost  certainly  there  will  later  be  stiffness  and  weak- 
ness of  the  back,  impairment  of  function  in  arm  or  leg,  muscular  atrophies 
frequently  with  e(jntractures,  urinary  troubles  of  greater  or  less  severity, 
neuralgias,  ataxias,  mental  disturbances,  one  or  more  ;  in  other  words,  the 
jirimary  lesion,  if  it  does  not  kill,  may  be  expected  to  be  followed  by 
ciironic  inflammations  and  scleroses  that  cannot  but  be  greatly  disabling, 
the  effects  of  which  may  not  perhaps  be  manifested  for  years.  When  a 
nerve  has  been  damaged  close  to  its  intervertebral  foramen,  the  parts  to 
which  it  is  suj>plied  will  be  found  to  be  seriously  affected  as  respects  both 
sensation  and  motion. 

Treatment,  aside  from  that  to  protect  against  infection  and  that  of 
the  ordinary  complications  of  spinal  injuries  in  general,  has  reference  to 
the  removal  of  foreign  bodies  and  the  securing  of  rest  to  the  injured  part. 
When  the  bullet  has  been  located  and  its  extraction  is  feasible,  it  should 
be  taken  away  and  the  wound  cleared  of  such  non-adherent  bone-fragments 
as  can  be  found.  Sometimes  the  extraction  of  the  ball  has  been  followed 
by  hemorrhage  sufficient  to  necessitate  plugging.  Karely  has  ligation  of 
an  artery  been  required.  Recently  nnich  attention  has  been  directed  to 
the  performance  of  laminectomy  for  the  relief  of  pressure,  whether  caused 
by  a  displaced  fragment,  by  a  blood-clot,  or,  later,  by  an  overgrowth  of 
bone.  In  the  present  state  of  surgical  jiractice  a  jiroperly-conducted 
operation  of  this  sort  does  not  mateinally  add  to  the  dangers  of  the  ease, 
and  permits  of  a  determination  of  the  condition  of  the  theca  and  cord, 
the  removal  of  whatever  may  be  pressing  upon  the  medulla,  the  extrac- 
tion sometimes  of  a  l^all  lodged  in  the  body  of  the  vertebra,  and  the 
thorough  cleansing  of  the  wound.  To  open  up  the  canal  a  trephine  may- 
be employed,  or,  better,  the  chisel  and  the  cutting  forceps.  In  gunshot 
even  more  than  in  other  fractures  of  the  spine,  operative  interference 
promises  to  be  of  veiT  much  service,  freed  as  the  operation  now  is  of  the 


WOUNDS  OF  liEGIONS.  495 

greater  part  of  the  danger  of  lighting  uj)  a  septic  raeningo-myclitis.  If  it 
does  no  good,  it  will  ordinarily  do  no  harm.  The  cases  in  which  it  iias 
been  done  are  as  yet  too  few  to  permit  of  tiieir  statistics  being  regarded 
as  establishing  a  rule  of  conduct ;  but  mere  numbers  of  reported  deaths  and 
recoveries  ouuht  never  to  be  so  regarded.     Sound  reasonina-  and  observa- 

o  o  o 

tion  of  the  analogous  ordinary  accidents  of  civil  life  certainly  now  justify 
— more,  authorize — the  operation  in  any  case  in  which  there  is  not  such 
associated  injury  of  vessel  or  organ  as  makes  recovery  under  any  circum- 
stances imlikely.  The  coexistence  of  any  serious  visceral  lesion  contra- 
indicates  any  operative  interference.  Whether  an  operation  is  done  or 
not,  the  spine  should  be  immobilized  and  rest  as  absolute  as  possible 
secured  to  the  patient. 

Chest. — A  considerable  proportion  of  the  wounded  in  action  (6,  8, 
even  10  per  cent,  of  those  receiving  treatment  during  a  given  war,  and 
one-third  to  one-half  of  those  killed  outright)  have  been  found  to  have 
been  shot  in  the  chest.  In  civil  life  such  injury  has  been  frequent,  ])i'o- 
duced  either  accidentally  or  with  intention.  The  wound  may  be  of  the 
parietes  or  involve  the  cavity  by  jienetration  or  perforation,  and  if  of  the 
chest-wall  may  be  associated  with  fracture  (costal,  sternal,  vertebral,  clavic- 
ular, or  scapular)  or  with  lesion  of  an  important  vessel  or  nerve. 

When  there  is  no  such  complication  a  non-penetrating  wound  is  usually 
one  of  little  moment — simply  a  flesh  wound,  to  be  treate<l  in  the  ordinary 
way.  Formerly,  especially  when  the  round  ball  was  used,  the  missile  at 
times  ran  for  a  greater  or  less  distance  around  the  chest,  but  such  course 
will  not  be  taken  by  the  bullet  of  to-day,  pistol  or  rifle ;  the  exceptions 
to  this  rule  being  only  apparent,  involuntary  muscular  action,  as  shown 
by  Bardeleben,  so  changing  the  position  of  the  parts  as  to  cause  the  actual 
straight  line  to  seem  to  be  a  curved  one. 

As  the  result  of  the  blow  upon  the  chest,  concussion  of  the  lung  in 
greater  or  less  measure  occurs,  indicated  by  difliculty  of  breathing,  pain, 
and  the  symptoms  of  shock,  all  usually  of  but  temporary  duration. 
When  the  force  of  impact  has  been  very  great,  commonly  in  shell-frag- 
ment injury,  contusions  of  the  hmg-surface,  lacerations,  or  injuries  of 
the  main  blood-vessels  have  occasionally  been  observed,  the  parts  being 
forcibly  compressed  between  the  chest-wall  (the  elasticity  of  which  per- 
mits of  its  being  strongly  crowded  backward)  and  the  distended  lung, 
the  air  in  which  may  be  held  in  place  by  an  associated  closure  of  the 
glottis.  In  such  injuries  the  concussion  symptoms  just  mentioned  are 
more  severe,  those  of  collapse  are  not  seldom  added,  and  a  quickly  fatal 
termination  has  at  times  been  reached — an  almost  certain  result  when  the 
laceration  has  been  extensive.  The  occurrence  of  bone-lesion  decidedly 
increases  the  gravity  of  the  case,  though  in  less  degree  now  than  prior  to 
the  adoption  of  the  antiseptic  method  of  treatment ;  and  danger  from  this 
cause  may  be  expected  to  be  less  in  future  wars  than  in  those  of  the  past 
in  proportion  as  the  new  bullet  is  smaller  than  the  old  and  produces 
less  separation  of  fragments.  The  sternum  may  be  grooved,  and  with 
the  groove  made  by  the  modern  missile  there  will  ])rol)ably  be  fissures, 
and  very  likely  a  transverse  crack  through  the  entire  thickness  of  the 
bone  ;  the  rib-fracture  M'ill  almost  certainly  cause  injury  to  the  pleura  ; 
the  clavicle  may,  though  very  rarely,  be  transversely  broken  without 
splintering — ordinarily  its  fracture  will  be  compound  and  conuninuted  ; 


496  GUNSHOT  WOUNDS. 

tlie  scapula  may  be  perforated  or  extensively  splintered ;  tlie  vertebral 
injuiy  will  commonly  be  of"  tlie  sjiinous  jjrocess  without  injtu-y  to  the 
cord  or  its  coverings.  The  gravest  of  the  non-penetrating  woiuid.s  are 
those  in  which  the  axillary  vessels,  those  just  above  the  clavicle,  or 
those  around  the  scapula  have  been  M'ounded,  a  decided  proportion  of 
which  are  quickly  fatal.  Karcly  met  with,  these  vessel-injuries  may 
be  more  conveniently  considered  in  comiection  with  perforating  K'sions, 
of  which  they  are  at  times  complications.  Taken  all  together,  the 
external  chest-wounds  have  a  very  low  mortality-rate  (1.5  per  cent, 
in  our  war — 1  per  cent,  only  excluding  the  fracture  cases).  Their 
treatment  is  the  ordinary  antisejitic  one,  combined  with  comfortably 
firm  bandaging  of  the  chest  or  immobilization,  as  fiir  as  may  be  jirac- 
ticable,  of  the  whole  thoracic  region.  When  pneumonia  or  pleuro- 
pneumonia comes  on  in  consequence  of  lung  contusion  or  laceration,  it 
is  to  be  treated  in  the  usual  way,  though  in  the  absence  of  the  specific 
infective  organisms  of  true  pneumonia  or  those  of  suppuration  the 
traumatic  inflammations  arc  of  mild  character. 

Of  far  greater  severity,  though  fortunately  of  decidedly  less  fre- 
quency as  they  come  under  care,  are  the  penetrating  and  ]>crforating 
lesions.  Among  wounds  received  in  action  hereafter  rarely  will  there 
be  found  one  of  the  former,  the  new  bullet  almost  certainly  passing 
through  and  out,  and  in  the  large  majority  of  pistol-shot  wounds  the 
ball  is  now  found  to  jierforate  either  comj)letely  or  so  far  as  the  thoracic 
cavity  is  concerned.  The  result  is  and  will  be  that  a  larger  percentage 
of  the  cases  not  quickly  fatal  do  and  \vill  get  well,  freed  as  they  must 
be  more  or  less  completely  from  the  dangers  of  suppurations,  fistulte, 
and  septic  infection.  Prompt  healing  characterized  the  cases  observed 
by  Stitt  in  the  late  Chilian  AVar.  Even  when  the  ball  has  lodged,  if  let 
alone  it  commonly  does  no  harm  when  an  aseptic  or  antiseptic  state  of 
the  wound  is  secured.  Never  again,  probably,  will  the  death-i'ate  of 
the  cases  treated  reach  80  or  90  per  cent.,  as  in  the  Crimea,  or  65  per 
cent.,  as  with  us,  or  68  per  cent.,  as  in  1870-71.  Very  much  more  than 
half  of  the  pistol-shot  cases  in  our  ho.spitals  recover ;  indeed,  death  is 
exceptional  in  those  not  almost  necessarily  fatal  from  the  nature  of  the 
injury. 

Wounds  of  both  lungs,  the  shot  having  passed  from  side  to  side  or 
very  obliquely  antero-i:)Osteriorly,  are  and  nuist  be  grave  lesions,  because 
of  shock,  hemorrhage,  or  developed  septic  inflammations,  but  because 
of  the  smaller  smoother  bullet  and  protection  from  sepsis  they  are  now, 
and  will  be  in  the  future,  less  frequently  than  heretofore  followed  by 
death. 

Multiple  wounds  are  but  little  if  any  more  dangerous  because  of 
their  number,  their  gravity  being  determined  by  the  character  of  the 
individual  injuries. 

That  penetration  has  occurred  may  or  may  not  be  clearly  ap])arent, 
the  only  positive  proof  of  lung-wound  being  afforded  by  ])rotrnsion  of 
a  part  of  the  organ  (primary  hernia),  the  regular  to-and-fro  j)assage  of 
air  synchronously  with  the  respiratory  movements  (traumatopncca),  actual 
inspection  of  the  lung  through  the  wound,  or  upon  digital  exploration. 
The  evidence  from  neither  sight  nor  touch  is  obtainable  in  the  ordinary 
bullet  wounds  of  to-day,  and  the  hernia  and  peculiar  breathing  only  very 


WOUNDS  OF  REGIONS.  497 

rarely  are  to  be  observed.  Probing  should  not  be  resorted  to,  as  if  the 
diagnosis  cannot  be  otherwise  made  it  is  not  necessary  to  establish  it,  and 
much  harm  may  easily  be  done  by  such  exploration.  ^Vhen  there  is 
present  a  wound  of  exit  as  well  as  one  of  entrance,  and  the  line  joining 
them  passes  through  the  cavity,  it  may  now  be  taken  for  granted  that 
there  has  been  penetration,  for  deflection  of  such  Ijidlets  as  are  in  use 
(i)ther  than  perhaps  the  smallest)  will  not  occur.  Emphysema  also  might 
be  regarded  as  proof  positive  were  it  not  for  the  fact  that  in  a  limited 
degree  it  may  be  present  in  a  non-penetrating  injury,  air  sucked  in  from 
without  being,  because  of  the  valvular  character  of  the  track,  prevented 
from  entirely  escaping  upon  expiration. 

The  ratit>nal  symptoms,  in  general,  ai'e  pain,  difficult,  or  more  prop- 
erly constrained,  breathing,  spitting  of  blood,  and  cough  ;  there  being  in 
addition,  when  air  or  blood  in  quantity  is  in  the  pleural  sac,  compression 
of  the  lung  on  one  side  with  tliminution  or  arrestation  of  the  chest  move- 
ments on  that  side,  increased  resonance  on  jiercussion  when  air,  dimin- 
ished Avhen  blood,  is  present,  with  shock  or  collapse  symptoms  in  greater 
or  less  degree.  Penetration  may  occur  without  injury  to  any  part  other 
than  the  pleura,  the  ball  cutting  it  in  passing  across  the  chest  between 
two  ribs — an  accident  )irol:iably  of  very  infrequent  occurrence,  very 
luilikely  to  be  recognized,  and  without  interest  except  such  as  attaches 
to  the  non-penetrating  wounds. 

Complicating  these  wounds  are  hemorrhages,  lodgement  of  foreign 
bodies,  fractures,  accunudations  of  air  or  j>us  in  the  plcui'a  or  (jf  pus  in 
the  mediastinum,  and  associated  lesions  of  the  spine  or  of  the  parts  below 
the  diaphragm.  The  bleedings  may  be  cither  external  or  into  the  chest- 
cavity,  the  former  when  other  than  slight  being  ordinarily  from  the  large 
arteries  or  veins  in  the  neck  or  axilla,  the  latter  from  the  intercostals, 
or,  much  less  frequently,  the  internal  mammary  artery,  from  the  great 
vessels  in  the  chest,  or  from  the  heart,  those  from  the  last  two  sources 
commonly  causing  death  so  promptly  that  they  need  not  now  be  consid- 
ered. Bleeding  from  the  lung-tissue  is  ordinarily  not  very  abundant, 
especially  when  the  wound  is  toward  the  periphery  of  the  organ,  though 
to  it  is  to  be  attributed  the  bloody  expectoration  which  is  so  frequently 
observed  during  the  tirst  few  days,  and  in  some  cases  the  produced  hemo- 
thorax— a  complication,  so  far  as  it  comes  under  treatment,  commonly 
due,  ho^vever,  to  injury  of  the  intercostals.  Tlie  hemorrhages  from  the 
axillary  or  subclavian  may  be  either  primary  or  secondary,  in  the  former 
case  the  blood  being  discharged  externally  or  infiltrating  the  surrounding 
tissues,  forming  a  fiilse  aneurism.  In  a  few  cases  late  opening  of  the 
subclavian  has  been  consequent  upon  the  fretting  away  of  the  arterial 
wall  by  the  rough  end  of  a  clavicle-fragment. 

The  lodged  foreign  bodies  have  usually  been  bullets,  which  have 
become  encysted,  remaining  at  times  for  years  without  doing  any  harm, 
or  have  been  coughed  up  or  by  ulceration  worked  tiicir  way  into  tiic 
oesophagus  to  be  later  discliarged  at  stool  (occurrences  that  have  been 
very  infrequent),  or  have  dropped  into  the  pleural  cavity  to  remain  or  to 
be  removed  after  ojjening  of  an  enqiycma.  No  such  lodgement  may  now 
be  looked  for  cxce]>t  in  a  small  minority  of  the  pistol-shot  wounds,  and 
in  these  cases  encaj>snlation  may  l)e  expected  very  generally  to  I'ollow. 

Fractures  are  of  much  less  importance  as  complications  than  hereto- 

VoL.  I.— 32 


498  GUNSHOT   WOUNDS. 

Cove,  except  wlicii  frnirnK'nts  of  tlie  broken  l)one  (coninioiily  a  rib)  are 
detached  and  driven  into  tlie  bnijj;,  and  even  tlien  tlie  resulting  danger  is 
decidedly  less  than  formerly.  Protected  from  the  development  of  septic 
intlammations,  neither  a  costal  nor  a  sca])ular  fracture  produced  by  an 
outgoing  ball  adds  materially  to  the  gravity  of  the  case.  Heretofore  frac- 
tnre  of  both  scapulfe  has  been  largely  a  fatal  injury,  but  will  be  so  here- 
after only  as  the  result  of  associated  lesion  of  the  spine  or  of  important 
structures  in  front  of  it. 

Pneumothorax  is  but  little  likely  to  follow  \vounds  made  by  the  mod- 
ern small-calibred  ball,  and  is  very  rarely  seen  to  any  serious  extent  after 
pistol-shot  injuries. 

Pus-collections  in  the  lung,  the  mediastinum,  or  the  pleural  sac  must 
also  be  much  less  frequent  than  before,  though  no  antiseptic  treatment 
can  be  pursued  that  will  prevent  such  infection  of  the  blood-clot  in  tlie 
pleural  cavity  as  is  j)roduced  by  organisms  coming  in  through  the  air- 
passages,  or  overcome  the  .septic  influences  of  discharges  into  the  medias- 
tinum from  an  opened  oe.sophagus — a  complication  of  extreme  rarity,  yet 
which  may  be  present. 

Associated  wound  of  the  abdomen,  as  might  be  expected,  is  one  of 
the  graver  com])lications,  about  three-quarters  of  the  cases  terminating 
fatally,  but  fortunately  is  not  very  common,  having  been  observed  in 
less  than  1.5  per  cent,  of  the  chest- wounds  reported  by  Otis.  In  civil 
life  the  frequency  is  greater,  but  the  mortality  less. 

In  a  limited  number  of  cases,  though  the  patient  does  not  die,  the 
recovery  is  imperfect,  the  lung  being  contracted  and  bound  down  by 
adhesions  or  being  the  seat  of  chronic  inflammations  or  tubercular  de- 
posits ;  fistulie  may  be  persistent ;  lateral  curvatures  of  the  spine  may 
be  induced,  etc. 

The  treatment  of  these  penetrating  wounds  consists  chiefly  in  secur- 
ing rest.  Shock,  if  severe,  may  necessitate  the  administration  of  ether 
or  strychnia  by  the  mouth  or  hypodermically,  alcoholic  stimulants  being 
avoided  as  much  as  possible.  No  search  for  a  lodged  liall  should  be 
made ;  if  it  can  be  felt  in  the  chest-wall,  it  may  be  removed  at  once  or 
left  undisturbed  for  some  days  until  the  track  may  have  so  far  healed 
as  to  ensure  jDrotection  against  any  possible  infection  of  its  deeper  part. 
Any  bleeding  vessel  that  is  in  sight  should  be  tied.  The  wound  or 
wounds  should  be  thoroughly  cleansed  and  closed  with  sterilized  gauze, 
and  then  the  chest  immobilized  as  far  as  practicable  and  rest  as  abso- 
lute as  possible  maintained.  Lately  it  has  been  advised  to  efl'ect 
immobilization  by  the  ajiplication  of  the  plaster-of-Paris  jacket,  and 
a  series  of  twenty  successful  cases  of  pistol  wounds  thus  treated  has 
been  reported  from  the  City  Hospital  of  St.  Louis.  The  effect  of  immo- 
bilization, in  whatever  way  it  may  be  eftected,  is,  by  restraining  the 
movements  of  the  damaged  part,  to  lessen  bleeding,  to  jirevcnt  the  occur- 
rence of  inflammation,  to  favor  absorjition  of  cfl'usions,  exudations,  or 
extravasations,  and  to  secure  more  rapid  healing  of  the  track.  If  there 
is  troublesome  bleeding  from  an  intercostal  vessel,  recourse  should  be 
had  to  ligati(3n  or  compression,  the  ligature  being  applied  directly  to  the 
artery  or  thrown  around  the  rib,  and  compression  made  by  ha?niostatic 
forceps  or  by  tampon.  Similar  treatment  should  be  ajijilicd,  if  jiossiljle, 
to  a  bleeding  internal  mammary  artery  ;  fortunately,  wound  of  this  vessel 


WOUNDS  OF  REGIONS.  499 

is  very  rarely  observed.  Hemorrhage  from  lesion  of  a  large  external 
vessel  above  or  below  the  clavicle  should  he  arrested  whenever  it  can  be 
done  by  the  aj)plication  of  a  ligature,  and  such  operation  must  certainly 
prove  less  dangerous  hereafter  than  heretofore  (75  to  85  per  cent,  mor- 
tality of  the  subclavian  and  axillary  ligations) ;  if  for  any  reason  ligation 
cannot  be  eifeeted,  compression  must  be  employed.  Hiemothorax,  if  the 
accumulation  is  large  and  the  produced  dyspnoea  great,  may  be  treated 
by  aspiration,  but  it  ('ertainly  is  better  freely  to  lay  ()i)en  the  chest, 
remove  the  clot,  ami  wash  out  tiie  pleural  cavity — treatment  impera- 
tively demanded  at  once  if  tlic  clot  becomes  infected,  as  indicated  by 
the  ordinary  symptoms  of  septic  infection. 

Empyema  should  always  be  treated  by  incision,  with  exsection  of  a 
piece  of  rib  sufficiently  large  to  ensure  free  drainage.  An  Estlander 
operation  may  be  required  under  conditions  similar  to  those  making  it 
proper  in  eases  not  consequent  upon  gunshot  injury. 

Suppurative  intlammations  in  the  mediastinum  necessitate  prompt 
and  tiiin'ougii  opening  of  the  abscess  and  careful  drainage,  any  foreign 
body,  ball,  bone,  or  other,  lodged  in  the  space  being  removed. 

Should  an  cesopliageal  M'ound  be  recognized,  the  patient  must  be  fed 
througli  a  tube  carried  into  tiie  stomacii ;  but  as  only  two  cases  of  such 
woun<l  are  on  record,  and  one  of  these  is  doubtful  (Delorme),  there  is 
little  likelihood  of  this  l)ein":  found  necessarv.  ' 

Here,  as  in  the  extremities,  fractures  are  to  be  treated  largely  expect- 
antly, completely  detached  fragments  only  being  taken  away.  The  sharp 
ends  of  a  broken  rib  or  clavicle  may  very  properly  be  taken  off  with  the 
cutting  forceps.  In  scapular  wounds  no  effort  to  remove  fragments 
should  be  made,  since  such  fragments  are  so  generally  held  in  place  by 
periosteal,  muscular,  or  fascial  attachments  tiiat,  protected  from  sepsis, 
their  reunion  may  be  looked  for.  If  necrosis  of  tlie  bone,  partial  or  com- 
plete, occurs,  late  sequestrotomy  may  be  safely  performed. 

Secured  from  infection,  no  lung  inflammation,  pro]ierly  speaking,  will 
be  developed,  the  reparative  changes  going  on  about  the  track  of  the  ball 
giving  rise  to  little  or  no  constitutional  disturbances  and  requiring  no 
special  treatment.  If  true  pneumonia  is  lighted  up,  it  must  be  cared  for 
in  the  ordinary  way,  as  also  any  localized  suppurations  or  gangrene. 

Hernia  of  tiie  lung,  should  it  be  present,  necessitates  return  of  the 
protrusion,  and  its  retention  by  an  appropriate  compress  and  bandage. 
Such  complication,  which  may  occur  at  once  through  the  wound  or  later 
under  the  skin  because  of  inq)erfect  closure  of  tlie  o])ening  in  the  chest- 
wall  or  of  yicl<ling  of  the  cicatrix,  lias  always  been  of  extreme  rarity,  and 
is  very  unlikely  ever  to  be  associated  with  wounds  made  by  the  small 
bullets  of  the  present  time.  The  same  is  true  of  omental  and  intestinal 
protrusions,  which  Iiave  been  liuown  to  occur  when  a  shot  has  passed 
through  the  seventh,  eigiith,  or  ninth  intercostal  space,  especially  the 
latter,  and  tlie  diaphragm  lias  been  wounded,  jiarticularly  on  the  left  side. 

In  civil  life  a  proper  antise})tic  treatment  will  almost  certainly  be  fol- 
lowed by  speedy  recovery  in  cases  not  necessarily  fatal  from  the  character 
and  extent  of  the  wound ;  and  the  same  may  be  hoped  for  in  military 
practice  in  proportion  as  it  is  possible  to  institute  and  maintain  such 
treatment. 

Heart. — These   injuries,  of  not  very  frequent  occurrence  and  still 


& 


500  GUNSHOT  WOUNDS. 

less  often  coniinjr  under  treatment  beeaii.se  of  tlieir  sreat  primary  mor- 
tality, are  either  contusions,  openings  of  the  pericardium,  t)r  [)euetrations 
or  perforations  of  the  heart  itself. 

Contusions  must  generally  be  consc(juent  uj)on  the  imjjact  of  a  missile 
the  velocity  of  which  is  almost  spent,  though  even  then  there  may  be  force 
enough  left  to  cause  a  laceration  of  the  heart  or  of  its  envelope. 

Oj)ening  of  the  perieardiuiu  without  visceral  wound  can  l)e  caused 
only  by  a  tangential  blow,  and  its  diagnosis  nuist  commonly  remain 
doubtful. 

Penetration  of  the  organ  with  lodgement  of  the  missile  (almost  cer- 
tainly in  the  ventricular  wall  or  septum,  occasionally  in  the  cavity)  will 
be  met  with  only  in  pistol-ball  or  small-shot  injuries,  the  bullet  of  the 
service  rifle  always  perforating. 

As  might  be  expected  from  the  anatomical  relations  of  the  parts, 
wound  of  the  pleura  with  or  without  wound  of  the  lung  very  generally 
accompanies  the  heart  wound. 

Though  the  prognosis  is  very  grave,  yet  life  may  be  prolonged  for 
days,  weeks,  or  even  months  (o^■er  three  years  in  a  case  personally  ob- 
served '),  a  blood-clot  or  contractions  of  the  muscular  filjres  closing  the 
wound  until  organic  union  can  be  effected.  Fischer  found  in  the  cases 
analyzed,  72  in  number,  16  per  cent,  of  recoveries,  a  percentage  doubt- 
less much  higher  than  it  really  is.  In  the  cases  that  do  not  quickly  die 
a  heart  lesion,  pericardial  or  endocardial,  almost  certainly  remains.  The 
chances  of  recovery  are  much  greater  in  wounds  of  the  ventricles  than  in 
those  of  the  auricles,  injury  of  the  right  ventricle  being  less  dangerous 
than  that  of  the  left. 

Whether  penetrating  or  perforating,  it  matters  not — for  ordinarily  the 
one  class  of  injuries  cannot  be  diagnosticated  from  the  other — the  symp- 
toms of  these  wounds  are  tluise  of  profound  shock  and  collapse,  with  great 
irregularity  of  the  pulse  and  alteration  of  the  heart-sounds,  the  bruits 
being  confused  and  confusing.  In  the  case  mentioned  of  extraordinary 
prolongation  of  life  they  were  of  the  most  bizarre  character,  blowing, 
churning,  rasping,  altogether  unlike  those  ordinarily  heard.  There  may  be 
considerable  hemorrhage  from  the  wound,  or,  as  often  hapjiens,  the  blood 
may  accumulate  in  the  pericardium,  l)y  its  pressure  much  enfeebling  the 
heart's  action.  When  there  is  such  jjcricardial  extravasation  there  is  a 
mucli  increased  area  of  dulness  on  percussion  ;  the  opposite  condition  of 
exasaerated  resonance  has  been  noticed  in  a  few  cases  in  which  there  was 
an  accumulation  of  air  in  the  cavity.  Very  rarely  has  a  suppuratnig 
pericarditis  been  observed. 

The  treatment  should  be  directed  toward  relieving  shock,  arresting 
hemorrhage,  and  controlling  the  heart-inflammations,  the  wound  being 
antiseptically  closed  and  the  chest  innnol>ilized.  When  there  is  a  dis- 
turbing amount  of  blood  in  the  pericardium,  jiaracentesis  should  be  cm- 
ployed,  or,  better,  free  incision  of  the  sac — an  operation  Avhich  cannot 
materially  increase  the  existing  danger  and  may  prove  of  great  benefit. 
Suturing  of  the  wound  in  the  heart-wall  has  been  proposed  ;  it  is  not 
likely  to  be  often  done. 

Abdomen.— About  1  in  30  of  those  wounded  in  the  ^vars  of  the  last 
half-century  and  1  in  9  of  those  killed  in  action  were  shot  in  the  abdo- 

'  Reported  in  Tlie  Clinic,  t'incinuati,  1876,  x.  253. 


WOUNDS  OF  REGIONS.  501 

men.  In  approximately  equal  proportion  the  wonnds  have  been  found 
to  be  of  the  ])arietes  outside  the  peritoneum  and  intra-peritoneal,  pene- 
trating or  perforating.  Hereafter  the  army  bullet  will  almost  certainly 
go  through,  the  only  foreign  bodies  lodging  being  pieces  of  cloth  or  other 
substances  accidentally  carried  in.  In  civil  practice  the  deep  wounds  are 
much  the  more  comuKm,  certainly  so  as  cases  present  themselves  in  hos- 
pital, and  their  ratio  to  the  whole  number  of  gunshot  injuries  is  higher; 
very  possibly,  however,  their  universally  recognized  gravity  causes  them 
to  be  more  generally  brought  under  such  care. 

Of  the  extra-peritoneal  wounds  a  few  are  contusions,  l)ut  in  the  great 
majdrity  the  missile  has  either  entered  and  lodged  or  passed  through  the 
wall  without  damaging  the  serous  membrane.  Contusions  have  become 
less  and  less  common  as  impi'ovements  have  been  made  in  weapons  and 
poM'der.  Generally  produced  by  spent  shot,  they  are  very  apt  to  be 
complicated  by  visceral  lacerations,  which  have  caused  death  in  from 
one-half  to  two-thirds  of  the  whole  number  of  cases.  In  tlie  milder 
injuries  muscle-rupture  has  been  frequently  observed,  and  gangrene  of 
the  damaged  area  with  after-suppurations  in  the  wall.  When  internal 
lesions  are  not  present  the  treatment  is  a  simple  antiseptic  one,  with  as 
absolute  rest  of  the  parts  as  can  be  secured ;  but  if  because  of  profound 
shock  and  collapse  there  is  good  reason  to  believe  that  visceral  ruptiu'e 
has  occurred,  laparotomy  should  be  done,  though  the  prospect  of  saving 
life  is  but  slight.  In  civil  life  these  contusions  are  very  unlikely  to  be 
met  with. 

When  the  missile  has  merely  passed  into  the  wall,  whether  it  stops 
or  goes  out,  the  wound  produced  is  an  ordinary  flesh  one,  the  dangers  of 
which  are  hemorrhage  and  septic  infection.  Foreign  bodies,  if  they  can 
be  located,  should  be  extracted,  though  there  is  not  now  the  same  neces- 
sity for  finding  them  as  in  former  times  ;  bleeding,  if  severe  or  persistent, 
as  it  often  is,  should  be  arrested  by  ligation  of  the  vessel,  free  incisions 
being  made  if  recpiired  ;  and  a  most  careful  antiseptic  dressing  should  be 
applied.  Under  such  treatment  there  is  no  good  reason  why  healing 
should  not  very  generally  and  readily  take  place,  and  the  mortality-rate 
be  decidedly  reduced  from  the  8  per  cent,  or  more  of  our  late  M'ar. 
When  the  injury  produced  l)y  the  shot  has  been  an  extensive  one,  there 
is  much  lial)ility  to  the  after-development  of  ventral  hernia. 

The  Wdunds  of  special  interest  are  those  in  which  the  peritoneal  cav- 
ity has  been  opened.  In  ])crhaps  3  per  cent.,  or  even  5  per  cent.,  of 
these  the  viscera  have  escaped  injury,'  but  the  probabilities  in  any  given 
wound  that  serious  damage  has  been  done  are  so  great  that  it  should  be 
assumed  as  a  fiict  that  such  has  been  the  case — certainly  so  if  the  ball 
has  ])assed  from  side  to  side,  the  antero-postcrior  woiuuls  only  being 
those  in  which  the  organs  may  escape.  The  intestinal  tract  is  the 
part  most  likely  to  be  wounded,  the  small  intestines  being  damaged 
four  times  as  often  as  the  large  ;  then  follow  in  order  of  frequency  the 
liver,  the  stomach,  the  kidney,  the  s|)leen,  the  pancreas.  Of  any  100  such 
wounds  as  tiiey  occurred  in  18(31-65,  tiicre  were  64  of  the  intestines,  17 

'  Recliis  and  Nogiife  found  this  condition  existing  in  1  out  of  38  experimental  shots; 
Senn,  in  4  out  of  14 ;  in  30  laparotomies  tabnlated  bv  MacCorinac  simple  penetrating  womid 
was  twice  fonnil ;  Senn  observed  it  in  2  of  his  (>  cases  of  operation  (in  one  of  which 
there  was  a  piece  of  cloth  in  the  cavity),  and  Kechis  and  Xogues  report  it  as  present  in 
17  out  of  123  collected  cases  of  shot  and  stab  wounds. 


602  GUNSHOT   WOUNDS. 

of  tlie  liver,  7f  each  of  the  stomach  and  kidney,  3  of  the  spleen,  and  J 
of  1  of  the  pancreas.  Ahiiost  certainly  the  lesions  are  multiple,  of  the 
hollow  viscera,  of  the  solid,  of  the  oiuciitiim  or  mesentery,  of  the  lung, 
of  the  great  vessels,  etc.  The  number  of  intestinal  perforations  aver- 
ages between  4  and  5,  and  has  been  knt)\\n  to  reach  as  high  as  16  or 
even  more. 

The  extent  of  damage  to  any  viscus  is  very  variable,  an  apparently 
explosive  action  being  at  times  oljserved  in  the  solid  viscera,  and  even  in 
the  stomach  or  intestine  when  full  of  Huid. 

The  general  mortality  has  been  very  high,  its  rate  being  in  our  war 
87.2  per  cent.,  and  in  various  wars,  as  tabulated  by  Otis,  75.1  per  cent. 
Even  in  the  less  grave  injuries  of  civil  life  caused  by  pistol  balls  the 
death-rate  has  until  recently  been  generally  much  above  oO  ]ier  cent.  In 
the  Chambers  Street,  the  New  York,  and  tiic  Roosevelt  hos])itals,  in  the 
vears  1876-84,  of  23  cases  treated  conservatively  15  died — 65  per  cent. 
(Stimson).  In  the  five  years  immediately  jireceding  iNIay,  1887,  of  32 
cases  in  the  Charity  Hosj)ital  of  New  Orleans,  19  died — 59.4  per  cent. 
(T.  G.  Richardson).  Of  91  cases  collected  by  Reelus  and  Nogues,  but 
22  died — 24  per  cent.  As  Ave  shall  see  later,  the  average  death-rate  of 
cases  operated  upon  during  the  last  ten  years  has  been  abt)ut  66.2  per 
cent. 

This  very  heavy  mortality  has  been  because  of  shock,  of  liemori-Jiage, 
and  of  septic  inflammation — of  the  latter  in  those  cases  in  A\hich  life  is 
prolonged  beyond  a  few  hours.  The  organisms  causing  such  inflamma- 
tion may  be  introduced  from  without  (chiefly  on  the  fingers  of  those  who 
handle  the  wounded  man  or  ujxm  the  instruments  of  the  surgeon),  are 
present  in  the  discharges  from  the  intestinal  canal,  have  been  carried  to 
the  damaged  area  in  the  blood-stream,  or  have  passed  through  the  un- 
wounded  bowel.  Shock  must  remain  as  heretofore,  but  under  modern 
methods  of  treatment  hemorrhage  can  be  largely  controlled  by  ligation, 
and  the  introduction  of  pyogenic  bacteria  from  without  be  prevented,  or 
their  deleterious  influence  when  introduced  from  within  in  some  measure 
lessened  by  thorough  cleansing  of  the  soiled  cavity  and  closure  of  the 
visceral  wounds.  In  both  hollow  and  solid  viscera  there  must  hereafter 
be  less  damage  done  by  the  small-calibred  bullet  than  was  formerly 
caused  by  the  large,  often  deformed,  mini&  ball,  at  least  outside  the  zone 
of  explosive  action. 

The  mortality  of  wounds  of  the  several  \-iscera  varies  within  rather 
wide  limits.  As  observed  in  1861-65,  it  was  of  the  liver  63.5  per 
cent.,  of  the  kidneys  66.2,  of  the  stomach  75.9,  of  the  pancreas  80,  of 
the  intestines  89.4,  and  of  the  spleen  93.1.  Of  50  cases  of  kidney 
wound  studied  by  Edler,  the  mortality-rate  of  the  20  uncomplicated 
wounds  of  the  organ  was  25  per  cent.,  and  of  the  30  in  which  there 
were  associated  wounds  of  importance  44  per  cent. ;  of  42  wounds  of 
the  spleen  83.37  per  cent.  died.  In  the  pistol-shot  wounds  of  civil  life, 
though  the  present  fatality  of  each  of  these  visceral  lesions  is  decidedly 
less,  there  is  still  a  marked  difference  between  them,  the  prognosis  of  in- 
juries of  the  stomach  or  of  the  large  intestine  being,  as  it  always  has  been, 
much  more  favorable  than  of  those  of  the  small  intestines.  In  all  of 
the  wounds  of  the  alimentary  tract,  those,  received  A\'hen  the  stomach  or 
bowel  is  emj)ty  are  less  dangerous  tiian  those  received  when  it  is  full. 


WOUNDS  OF  REOIONS.  503 

The  diagnosis  of  penetration,  at  times  easily  and  definitely  estab- 
lished, is  not  seldom  very  uncertain  in  default  of  an  opening  up  of  the 
track  of  the  ball  or  an  abdominal  sectii)n.  If  through  the  external 
wound  there  is  an  escape  of  intestinal  contents  or  of  l)ile,  or  ])rotrusion 
of  bowel,  omentum,  or  j)ortion  of  a  winuKled  solid  viseus,  there  can  be 
no  question  respecting  the  opening  of  the  cavity.  But  such  positive 
evidences  of  penetration  are  affordetl  in  but  a  minority  of  cases.  The 
presence  of  even  small  quantities  of  the  intestinal  contents  in  the  per- 
itoneal cavity  has  been  comparatively  rarely  noticed  in  pistol-shot 
wounds  operated  upon,  much  less  often  have  such  matters  been  dis- 
charged externally  ;  and  the  same  will  doubtless  be  true  of  the  injuries 
caused  by  the  new  bullet.  The  ojienings  are  often  so  small  that  they  are 
plugged  by  the  pouting  mucous  membrane  or  closed  by  changes  in  the 
parallelism  of  the  coats  of  the  bowel  or  by  the  adhesion  of  adjacent  coils 
of  intestine  oi'  omentum.  Sometimes  the  fecal  extravasations  have  occurred 
only  after  tlie  lapse  of  some  hours  or  even  days  (because  of  the  primary 
paralysis  of  the  bowel),  at  a  time,  therefore,  when  this  diagnostic 
evidence  is  of  little  practical  value.  Escape  of  bile,  indicative  of 
Hvei- wound,  may  be  expected  to  take  place  in  but  about  two-fifths  of 
the  cases  of  injury  of  that  organ,  only  probably  in  those  affecting  its 
central  part,  and  in  but  a  portion  of  these  cases  will  it  flow  out  through 
an  external  wound.  Hernia,  whether  of  intestine,  omentum,  or  of  a 
portion  of  a  damaged  solid  viseus,  very  rarely  occurs,  and  is  not  to  be 
ex]K'cted  in  M'ounds  made  by  pistol  balls  or  the  small-calibred  rifle 
bullet.  Otis  found  but  two  instances  of  bowel  protrusion  rej)orted  to 
the  Surgeon-General  during  our  war,  a  number  without  doubt  much 
smaller  than  that  of  the  cases  actually  occurring.  One  such  case,  of 
which  no  record  appears  in  the  Med.  and  Suiy.  Histori/,  came  under 
personal  observation  during  the  siege  of  Port  Hudson,  the  protruding 
knuckle  of  small  intestine  showing  perforation  wounds.' 

As  a  rule  having  few  exceptions,  the  diagnosis  of  penetration  will 
have  to  rest  upon  observation  of  the  position  of  the  wound — or,  better, 
wounds,  the  ball  having  gone  through — iqion  hemorrhage  from  the 
stomach  or  tlie  l)o\vel,  blood-stained  vomited  material,  extreme  shock, 
collapse  indicating  hemorrhage  in  considerable  amount,  or,  after  the 
lapse  of  days,  the  discharge  of  the  ball  at  stool.  Neither  shock,  nor 
vomiting  of  blood  or  blood-stained  mucus,  nor  bloody  stools  positively 
indicates  penetration  of  the  stomach  or  bowel,  as  either  may  possibly 
be  consequent  upon  contusion  ;  liut  the  occurrence  of  these  symptoms 
in  connection  with  the  location  of  the  wound  makes  the  diagnosis  very 

'  In  1872,  Asst.  Surg.  Patzki,  U.  S.  A.,  reported  to  the  Surgeon-General  from  Fort 
Clark,  Texiis,  an  accitrental  wound  made  by  tlie  ball  of  a  Derringer  pistol,  cal.  .3(5,  at 
1  foot  distance,  the  shot  entering  li  inches  above  the  umbilicus,  J  inch  to  the  right  of 
the  median  line,  and  lodging,  its  location  being  undetermined:  2.]  inches  of  the  omentum 
protruded.  On  the  seventh  day  after  the  injury  this  protruding  omentiuu  was  removed 
with  a  wire  ecraseur.  It  was  at  the  time  "  firudy  adherent  to  the  sides  of  the  wouud, 
thickened,  more  solid  (carnitied),  covered  with  grauulations  secreting  oticnsive  pus. 
Patient's  condition  very  good.  Vomiting  after  injury,  but  no  blood  in  the  vomited  matter 
or  stools.  The  protruding  ouientum,  being  useful  as  a  plug,  closed  wound  liermetically. 
No  attempt  made  to  return  it.  No  symptoms  of  internal  hemorrhage,  fecal  extravasa- 
tion, or  peritonitis.  Expectant  treatment."  Recovery  rapid ;  wound  cicatrized  eleven 
days  later.  Returned  to  duty  twenty  days  after  receipt  of  injury,  bullet  still  remaining 
in  the  bodv. 


504  GUNSHOT  WOUNDS. 

probaljlc.  A  Imll  ])assin^  from  side  to  side  at  or  below  the  level  of 
the  uiiibilicus,  at  such  deptli  beneath  the  highest  point  of  the  curve 
of  the  altdomiual  wall  as  will  more  than  carry  it  thmugh  the  thickness 
of  the  wall,  must  certainly  wound  the  intestines.  When  Seun  in  1888 
rejjorted  upon  the  results  of  the  experimental  rectal  insufflation  of 
hydrogen  gas,  it  was  hoped  that  there  had  been  found  a  sure  and  safe 
method  of  establishing  the  diagnosis  of  bowel-wound.  Hydrogen  gas 
slowly  and  continuously  introduced  under  a  pressure  of  from  l  to  2 
pounds  was  shown  to  pass  the  ilco-csecal  valve  and  traverse  the  entii'e 
length  of  an  uninjured  alimentary  canal,  while  if  there  was  a  wound 
at  any  point  it  would  escape  through  such,  distend  the  abdominal  cavity, 
obliterating  the  liver-dulness,  and  find  its  way  out  through  the  external 
shot-opening,  as  proved  Ijy  its  ignition  when  a  flame  was  l)rought  near 
such  opening.  Unfortunately,  experience  has  shown  that  the  test  is  not 
always  reliable,  the  passage  of  the  gas  being  at  times  obstructed  by 
fecal  accumulations  in  the  lower  bowel,  or  its  escape  externally  being 
prevented  by  adhesions,  ordinarily  omental,  at  the  inner  opening  of  the 
track  through  the  al)dominal  wall.  When,  then,  there  is  serious  question 
of  there  being  penetration,  the  wound  should  be  carefully  laid  open 
until  it  is  clearly  shown  that  it  does  or  does  not  involve  the  peritoneum. 
If  the  shot  has  passed  transversely,  the  cut  may  be  made  in  the  middle 
line,  when,  if  the  wound  is  extra-peritoneal,  its  track  will  be  crossed 
before  the  peritoneum  is  reached.  It  is  never  wise  to  explore  the  track 
of  the  ball  with  a  finger  or,  much  more,  a  probe,  since  penetration  may 
thus  be  made  in  cases  in  which  the  serous  membrane  has  not  been 
pierced,  or  adhesions  may  be  broken  up  or  hemorrhage  excited. 

Kidney  lesion  is  established  as  a  ])robability  liy  shock,  the  direction 
of  the  course  of  the  shot,  and  the  discharge  from  the  bladder  of  bloody 
urine,  though  the  latter  symptom  may  be  present  in  connection  with 
ureteral  contusion  or  laceration,  or  with  injury  of  the  bladder  itself. 
When  the  wound  is  from  behind,  the  visceral  A\ound  may  be  altogether 
extra-peritoneal,  and  urine  may  escape  externally  or  into  the  tissues 
about  the  organ.  If  there  is  associated  penetration  of  the  j>eritoneum, 
there  may  or  may  not  be  extravasation  of  urine  into  the  abdominal 
cavity. 

As  shown  by  Redard  in  1870,  grave  lesion  of  the  contents  of  the 
abdominal  as  of  the  cranial  and  thoracic  cavities  is  always  to  be  inferred 
when  there  is  from  the  beginning  for  four,  six,  or  more  hours  a  sub- 
normal temperature. 

The  occurrence  of  j)ei'it<initis  (which  if  it  is  developed  is  almost  cer- 
tain to  be  so  in  from  eighteen  to  thirty-six  hours)  is  indicated  by  the 
ordinary  symptoms  of  the  disease,  the  marked  acceleration  of  the  pulse 
(it  is  often  very  great)  being  of  much  more  diagnostic  value  than  the 
temperature-changes,  which  are  frequently  but  slight. 

Treatment  is  either  by  abstention  or  by  ojierativc  interference.  Up 
to  a  time  not  fifteen  years  ago  surgeons  generally  were  content  to  apply 
cold  ;  to  put  on  a  bandage,  even  of  plaster  of  I*aris  (Xeudorfer) ;  to  main- 
tain rest  as  absolute  as  possible  ;  to  feed  sparingly,  and  that  with  fluids  ; 
and  to  administer  opium,  given  at  times  with  so  free  a  hand  as  to  make  it 
questionable  whether  the  fatal  result  was  due  to  the  injuiyor  to  the  treat- 
ment.    But  the  death-rate  was  so  high  that  not  a  few  were  dissatisfied 


WOUNDS  OF  REGIONS.  505 

with  the  course  adupted.  Sims  had  advised  laparotnniv  that  l)lee<Hng 
vessels  might  be  toiuid  and  tied,  and  Bahr  had  reeonnnended  that  on  the 
battle-fiekl  the  wound  of  the  al5<h)niiual  wall  should  be  laid  open  and 
enlarged,  the  cavity  cleansed  of  fceal  matter,  and  the  wound  of  the  bo\vel 
closed  by  suture.  Otis  had  protested  against  the  "  do-nothing  system,"  and 
^leGiiire  had  urged  operation,  declaring  that  if  such  measure  was  a  desjier- 
ate  one  the  peril  was  so  extreme  that  under  the  usual  treatment  nearlv  all 
the  patients  died.  In  1881,  Kinloeh  did  an  exploratory  laparotomv  and 
closed  three  perforations  ;  two  years  later  Koclier  by  a  similar  operation 
saved  the  life  of  his  patient,  and  in  1884,  Bull  was  equally  fortunate,  his 
case  being  the  first  successful  one  in  our  country.  In  the  same  year 
Parkes  as  chairman  of  the  Surgical  Section  rejtorted  to  the  American 
]\Iedical  Association  the  results  of  many  experiments  upon  dogs,  and 
advised  and  urged  direct  operative  interference  in  all  intra-peritoneal 
wounds.  Since  that  time  the  ijuestion  has  been  not  whether  the  abdomen 
should  be  opened  and  lesions  treated  surgically,  but  in  what  cases  it  should 
be  done — or,  rather,  whether  or  not  it  should  be  done  always  and  as  soon 
as  possible.  To  answer  this  question  it  must  be  known  what  are  the  proba- 
bilities of  recovery  when  operation  is  not  done,  and  what  have  been  the 
results  of  the  sections  that  have  been   made. 

It  has  already  been  stated  that  in  three  of  the  New  York  hospitals 
65  per  cent,  of  the  cases  treated  expectantly  during  the  years  1876-84 
died  ;  in  the  Cliarity  Hospital  of  New  Orleans,  in  five  years  prior  to  May, 
1887,  59.4  per  cent,  died  ;  and  of  91  cases  collected  l)y  Reclus  and  Nogues, 
largely  from  journal  reports,  but  24  per  cent.  died.  Reclus  has  latelv 
reported  that  of  114  revolver  wounds  of  the  abdomen  treated  expectantly 
94  recovered — 82  per  cent.  The  experience  of  surgeons  generallv  has 
been  such  as  to  make  them  unwilling  to  accept  these  figures  of  Keelns 
(24  and  18  per  cent,  of  mortality)  as  representing  the  ordinary  death-rate 
at  the  present  time  of  the  wounds  under  consideration  when  ])roperly 
treated  by  abstention.  If  they  do,  such  treatment  is  very  mucii  better 
than  that  by  operation.  It  is  very  pi'obable,  though,  that  the  ordinarily 
stated  mortality-rate  is  too  high,  and  would  be  found  to  be  much  lowered 
in  the  practice  of  those  willing  to  carry  out  fully  and  fi^iithfully  the 
strictest  antiseptic  method,  and  capable  of  doing  so. 

Of  the  death-rate  after  operation  \ve  can  now  speak  quite  definitely. 
It  was,  in  the  eases  collected  by  Korte,  65.6  pev  cent.  (64—42) ;  by 
Reclus  and  Nogues,  78  ])er  cent.  (73-57) ;  l)v  ^lorton,  67.27  per  cent. 
(110-74);  by  Barrow,  66  per  cent.  (112-74);  by  Martin  and  Hare, 
66f  per  cent!  (129-86) ;  by  Coley,  67.27  per  cent.  (165-111).  Personal 
reports  from  fifty-five  of  our  American  surgeons  of  all  their  cases  give 
a  mortality-rate  of  70.66  per  cent.  (174-123).  Twenty-three  had  ope- 
rated l)ut  once,  with  a  death-rate  of  82.6  per  cent.,  nine  twice,  with 
death-rate  of  95  per  cent.  ;  eight  had  each  seven  or  more  cases,  aggre- 
gating 82  witli  50  deaths — 61  per  cent.  Here,  as  in  other  abdominal 
operations,  with  increased  experience  come  better  results.  In  no  small 
measure  certainly  this  larger  percentage  of  recoveries  is  due  to  more  rapid 
operating,  the  time  of  exposure  of  the  abdominal  organs  being  a  very 
important  factor  in  the  ease.  As  shown  by  ]\[artin  and  Hare,  an  opera- 
tion completed  in  an  hour  is  three  times  as  likely  to  be  followed  by  recov- 
ery as  one  completed  in  two  hours.   Of  necessity,  much  time  must  be  taken, 


606  GUNSHOT   WOUNDS. 

but  it  need  not  be  on  an  average  an  hour  and  tliree-f|narters,  as  stated  by 
Pclornie.  Tlie  tedious  part  of  the  o]H'ration  is  tlie  finding  of  tlie  ])erfora- 
tions  and  making  sure  tiiat  they  have  all  been  found.  Inch  by  inch  the 
small  intestine  must  be  examined,  either  laid  out  upon  the  abdominal  wall 
(protected  by  hot  sterilized  gauze  or  towels)  or,  much  better,  returned  to 
the  cavity  as  fast  as  it  has  been  inspected.  Proper  search  must  also  be 
made  for  any  wound  of  the  stomach,  the  large  intestine,  or  the  bladder, 
an<l  the  jjresence  or  absence  of  a  lesion  of  liver,  spleen,  or  kidney  deter- 
mined. All  this  takes  time,  and  time  means  risk,  and  not  seldom, 
notwithstanding  the  time  taken  and  care  exercised,  a  perforation  or  per- 
forations have  been  overlooked  by  the  best  of  surgeons.  Insufflation  of 
hydrogen  has  at  times  proved  of  much  service,  lieing  injected  from  ojien- 
ing  to  opening  from  below  nj)ward.  In  place  of  hydrogen,  atmospheric 
air  may  be  used.  Could  the  gas  or  air  Ije  always  relied  upon,  and  did 
not  its  use  expose  to  the  risks  of  forcing  open  perforations  already 
closed  and  of  expelling  fecal  matter  into  the  peritoneal  cavity,  it  would 
be  of  extreme  value  because  of  the  rapidity  with  which  the  wounds  can  be 
located. 

The  necessary  manipulations  of  a  la])arotomy  must  now  and  then  be 
the  cause  of  the  breaking  up  of  already-formed  protective  adhesions  of 
bowel  to  bowel,  of  bowel  to  omentum,  or  of  bowel  or  omentum  to  the 
abdominal  wall. 

The  earlier  the  section  is  made  the  better,  that  bleeding  may  be  arrested 
and  fecal  extravasation  ])revented,  or,  if  it  has  occurred,  that  the  exceed- 
ingly irritant  matter  may  Ijc  removed  before  it  has  had  time  to  exert  to 
the  full  its  deleterious  influence.  All  observation  has  shown  that  the 
chances  of  recovery  rapidly  diminish  as  the  hours  go  liy,  the  jiatient  com- 
paratively seldom  surviving  a  lapartitoni}-  done  a  half  day  or  more  sub- 
sequent to  the  shooting.  When  j)eritonitis  is  fully  developed,  death  is 
almost  sure  to  occur,  but  as  once  in  a  while  relief  is  afforded  by  operation, 
the  section  may  properly  be  made. 

In  civil  ])rai'tice  la])arotomy  should  always  lie  done,  and  that  at  once — 

1.  When  there  is  positive  evidence  of  penetration  in  the  protrusion  of 
bowel  or  omentum,  though  occasionally  recovery  may  take  place  with- 
out section  after  return  of  the  protrusion  or,  if  omental,  its  removal  at  the 
time  or  later ; 

2.  When  there  is  discharge  externally  of  fteces,  bile,  or  urine ; 

3.  When  severe  and  rapidly-developed  collajise  sho^\■s  that  a  large 
vessel  (or  vessels)  has  been  torn  ; 

4.  When  the  wound  has  been  made  by  a  bullet  of  other  than  small 
calibre,  particularly  if  it  is  at  or  below  the  umbilical  level,  and  especially 
if  the  shot  has  passed  from  side  to  side. 

In  field  service  it  will  be  quite  difficult,  and  often  altogether  impos- 
sible, to  treat  these  wounds  actively  ;  and,  as  military  necessities  may 
compel  at  times  an  early  removal  of  the  wounded,  this  of  itself  will  render 
a  successful  termination  of  an  ojieration  much  less  probable  than  after 
similar  work  in  a  well-organized  hosjiital. 

When  the  injury  has  been  inflicted  by  a  small  liall  of  calibre  not 
above  .22,  and  affects  probably  only  an  empty  stomach  or  the  colon  or 
one  of  the  solid  viscera,  operation  may  very  properly  be  postponed  so 
long  as  neither  local  nor  constitutional  symptoms  of  severity  are  present. 


wouyns  of  EEGioys.  507 

Though  stomach  wounds  made  by  a  large  bullet  are  among  the  gra%'er 
abdominal  lesions,  from  tiiree-quarters  to  seven-eighths  of  tiiem  in  18(Jl-65 
and  1870-71  dying  because  of  hemorrhage  or  extravasation  of  the  con- 
tents ol'  the  organ,  they  may  be  expected  to  be  much  less  dangerous 
when  produced  by  the  present  army  bullet,  unless  received  within  the 
zone  of  explosive  action.  As  met  with  in  civil  life,  where  they  are  often 
caused  by  small  bullets,  a  considerable  ])ro])ortion  may  be  recovered 
from  eitiier  with  or  witliout  operation.  The  same  is  true  of  liver- 
wounds,  in  many  of  which  the  diagnosis  without  section  is  quite  uncer- 
tain :  the  track  is  small,  the  bleeding  is  not  excessive,  jaundice  very 
rarely  occurs  (not  in  one  in  twenty  cases  probably),  even  a  lodged  ball 
may  be  well  borne,  and  if  bile  escapes  into  the  peritoneal  eavit_y  it  is 
very  much  less  irritant  tlian  was  formerly  supposed.  Kidney-wounds, 
if  made  from  behind  and  not  complicated  by  intra-abdominal  lesions, 
may  he  treated  expectantly,  unless  tiie  hemorrhage  is  great  or  there  is 
urinary  intiltration  of  the  surrounding  tissues,  when  the  organ  should  be 
cut  down  u])on,  ligation  if  necessary  done,  and  free  escape  of  the  urine 
secured,  or,  if  the  organ  is  much  injured,  nephrectomy  performed.  There 
is  douljtless  much  v.isdom  in  Titlany's  suggestion  to  treat  the  kidney- 
wound  like  any  other,  suturing  it,  draining  it,  and  removing  so  much 
of  the  viscus  as  lias  been  disorganized,  remembering  that  if  necessary  the 
whole  kidney  can  later  be  taken  away,  and  that  with  less  risk  than  at- 
tends a  primary  operation.  Often  wounds  of  this  organ  are  complicated 
with  those  of  the  liver  or  the  vertebra. 

The  teclini(]ue  of  laparotomy  for  gunshot  injury  is  in  the  main  that 
of  the  operation  for  otlier  causes.  Incision,  as  a  rule  iiaving  few  excep- 
tions, should  be  in  the  median  line,  and  not  tlirough  the  wound,  as  thus 
more  ready  access  may  be  had  to  all  parts  oi'  the  alidominal  cavity. 
Bleeding  should  be  first  attended  to,  clots  removed,  the  source  of  the 
hemorrhage  discovered  if  }iossible,  and  the  wounded  vessels  tied.  At 
times  an  intei'costal  artery  or  the  internal  mammary  has  been  wounded, 
and  not  seldom  one  of  the  large  vessels  of  tiie  pelvis ;  but  in  very  many 
cases  the  bleeding  is  from  the  mesentery  or  from  one  of  tlie  solid  viscera. 
If  active  bleeding  is  going  on,  it  may  be  temporarily  controlled  by 
compression  of  the  aorta  or  by  gauze  compresses,  so  that  the  parts 
mav  l)e  rendered  dry  enough  to  permit  of  the  vessel  being  seized  and 
tied. 

The  alimentary  tract  is  then  to  be  examined.  All  openings  in  the 
bowel  should  be  stitched  up,  except  those  so  large  that  their  closure 
must  be  followed  by  marked  constriction,  or  the  very  small  ones  that 
are  already  plugged  by  the  everted  mucous  membrane,  which  may  be 
left  to  tlieraselves  if  the  general  condition  of  the  patient  compels  quick 
completion  of  the  operation.  F'ue  silk  is  far  the  best  suture  material. 
Contused  patches,  if  the  injury  is  other  than  slight,  had  better  be  treated 
as  if  they  were  open  wounds,  or  they  may  be  covered  witii  an  omental 
graft,  which  latter  is  often  of  service  in  giving  additional  protection  to 
the  sewed  wound.  The  ordinary  I^embert  stitch  is  commonly  employed, 
and  as  far  as  possible  the  seam  should  be  made  tran.sversely.  When  the 
wounds  are  too  large  to  be  safely  sewed  uji,  the  damaged  section  of  tlie 
bowel  must  be  excised,  and  either  end-to-end  or  lateral  anastomosis  ef- 
fected, preferably  the  former  as  a  rule.     If  iatei'al  anastomosis  is  made, 


508  GUNSHOT   WOUNDS. 

excision  of  the  lacerated  l)owel  need  not  necessarily  he  done.  Plates  or 
buttons  may  he  used,  tliough  tliey  are  ntit  necessary.  Mesenteric  ojien- 
ings  shoidd  be  closed  and  any  bleeding  mesenteric  vessel  ligated,  either 
catgut  or,  better,  fine  silk  being  employed.  If  there  has  been  any  con- 
siderable laceration  of  the  omentum,  the  damaged  piece  shoidd  be  tied 
off'  and  cut  away. 

An  existing  wound  in  tlie  liver  should  be  sutured  if  it  can  be  done; 
if  not,  plugged  with  gauze,  a  drainage-tube  (jireferably  of  glass)  being 
used  if  necessary.  It  has  been  advised  to  always  take  away  a  l)adly- 
damaged  kidney,  but  partial  removal  will  doubtless  often  be  found 
sufficient.  Lesions  of  the  spleen,  if  much  disorganization  has  not  been 
produced,  may  be  treated  simply  ;  when  tlie  tearing  has  been  great 
splenectomy  is  certainly  indicated,  in  default  of  whicii  plugging  must  be 
resorted  to — a  method  of  treatment  which  nuist  be  used  if  tiiere  is  a 
wound  of  the  pancreas. 

Cleansing  of  the  abdominal  cavitv  should  be  verv  thoi'ough,  and  it  is 
in  this  part  of  the  ojieration  that  much  time  is  often  consumed.  The 
closure  of  the  external  wound  is  effected  in  the  usual  way,  a  drainage- 
tul)e  being  used  when  there  has  been  much  bleeding  or  much  soiling  of 
the  cavity  with  alimentary  matters. 

The  patient  must  be  kej)t  (juiet ;  shock  relieved  by  the  administra- 
tion hypodermically  of  ether  or  strychnia  (hot- water  douching  of  the 
ca\ity  is  of  great  value  in  relieving  shock  temporarily  while  the  opera- 
tion is  in  progress) ;  fluids  witidield  as  far  as  possiljle  for  at  least  twenty- 
four  hours  ;  and  after  that  for  several  days  an  absolute  milk  diet  observed, 
milk,  besides  its  value  as  a  food,  having  been  clearly  shown  to  have  a 
decided  germicidal  action.  As  after  the  moi-e  common  laparotomies,  the 
administration  of  saline  cathartics  is  of  service  in  relieving  gaseous  dis- 
tention and  preventing  peritonitis. 

In  a  limited  number  of  eases  (very  rarely,  however,  in  civil  practice) 
fistuhe  have  followed  abdominal  wounds,  almost  always  in  connection 
with  the  large  intestine.  The  spur  so  often  ob.servcd  in  artificial  anus 
after  hernia  has  been  very  infrequent.  Generally  these  ffstulas  have 
closed  spontaneously  in  the  course  of  a  few  months.  If  such  closure 
does  not  take  ]ilaee,  they  should  be  operated  upon  in  the  usual  way. 

Rectum. — Wounds  of  the  rectum  may  be  in  connection  with  those 
of  the  bowel  higher  up,  of  other  pelvic  organs,  of  the  ))oncs  of  the 
pelvis,  or  of  the  perineum  and  parts  adjacent.  In  tliemselves  they  are 
of  interest  chiefly  because  of  the  extensive  suppurations  and  gangrenes 
so  often  consequent  upon  fecal  extravasations  through  them.  Allien 
such  infection  of  the  connective  tissue  does  not  occur,  the  uncomplicated 
wound  heals  ra])idly,  and,  if  made  by  pistol  liall  or  small-ealibred  bullet, 
without  after-fistula  or  stricture. 

Even  the  necessarily  more  or  less  defective  antisepsis  that  can  be 
secured  in  military  practice  will  doubtless  be  sufficient  to  decidedly 
reduce  the  former  mortality-rate  of  wounds  of  this  kind  received  in 
action  (between  40  and  50  per  cent.) ;  and  it  may  reasonal)ly  be  expected 
that  in  the  perforating  injuries  that  will  be  made  by  the  new  bullet  there 
will  be  less  laceration  of  the  bowel  and  less  likelihood  of  extravasation, 
and  ]irobably  better  drainage  of  tlie  damaged  area. 

If  the  rectal  wound  is  but  one  of  several  intraperitoneal  lesions,  if  it 


WOUNDS  OF  REGIONS.  509 

<!an  be  gotten  at  it  should  be  stitcliod,  otherwise  the  gauze  tampon  must 
be  employed.  A  pistol-ball  injury  below  the  peritoneal  refleetion  will 
make  necessary  only  careful  cleansing  and  disinfection  of  the  bowel  and 
the  observance  of  the  ordinary  rules  of  wound-treatment ;  and  the  same 
is  true  of  any  uncomplicated  lesion  higher  up.  After  the  lower  bowel 
has  been  well  washed  out  with  an  antiseptic  fluid,  the  more  quiet  it  is  ke[)t 
the  better.  Surgeons  have  long  recognized  the  benetieial  ettects  of  the 
internal  administration  of  opium  given  in  dose  sufficient  to  constipate. 
If  because  of  infection  ischio-rectal  inflammation  occurs,  free  incisions 
must  be  promptly  made  and  an  antiseptic  treatment  thoroughly  car- 
ried out. 

Bladder. — Bullets  passing  into  or  through  the  pelvis  not  seldom 
MOund  the  bladder — much  more  frequently,  of  course,  when  the  viscus 
is  iull  than  when  it  is  em])ty.  These  shots  may  come  in  any  direction, 
and  very  generally  they  injure  some  part  of  the  bony  wall.  Not  neces- 
sarily so,  however,  for  they  may  enter  fi'om  above  or  from  below 
and  lodge  in  the  pelvic  cavity,  or  they  may  pierce  the  anterior  inferior 
abdominal  wall  just  above  the  pubes  and  emerge  through  a  sacro-sciatic 
foramen.  Their  course  usually  is  antero-posteriorly  with  more  or  less 
oblicjuity,  though  the  bladder  may  be  damaged  by  a  ball  passing  from 
side  to  side,  rarely,  h(jwever,  if  it  is  emptor.  Sometimes  the  vesical  wall 
is  so  pierced  as  to  prevent  escape  of  urine  in  any  considerable  amount, 
and  gutterings  without  penetration  may  take  place,  the  ball  track  ordi- 
narily, however,  soon  opening  up  by  ulceration. 

In  the  large  majority  of  cases  the  lesion  is  a  complicated  one,  the 
rectum  Ix'ing  conunonly  wounded  when  the  direction  of  the  bullet  is 
from  behind  forward  or  from  before  backward,  unless  the  momentum  is 
so  slight  that  the  shot  lodges  against  or  in  the  anterior  wall  of  the 
bladder  or  in  its  cavity.  In  not  a  few  of  the  cases  there  is  in  associa- 
tion so  serious  a  lesion  of  the  blood-vessels  of  the  region  that  death 
quickly  occurs  from  hemorrhage.  The  wound  may  be  in  a  part  of  tiie 
bladder  covered  with  peritoneum  or  may  be  cxtra-periton(>al,  the  gravity 
of  the  case  being  much  greater  when  in  the  former  situation,  extravasated 
urine  finding  its  way  into  the  abdominal  cavity  instead  of  into  the  con- 
nective tissue.  It  is  to  such  extravasation  with  its  resulting  septic  infec- 
tion that  death  is  commonly  due  in  cases  not  fatal  from  bleedingr  or 
from  associated  visceral  lesions. 

The  mortality-rate  of  cases  coming  under  care  in  military  ])ractice  has 
been  about  one-half  (45-55  per  cent.),  but  of  those  in  civil  life  early  and 
properly  treated  it  is  decidedly  less,  very  much  so  when  the  bladder  was 
empty  at  the  time  of  its  injury. 

The  symptoms  are — sliock,  pain  in  the  region  or  diffiiscd  over  the 
abdomen,  and  general  weakness,  eaeii  commonly  in  high  degree  ;  much 
irritaljility  of  the  bladder  and  rectum  ;  luematuria  ;  and  escape  of  urine 
tlirougli  the  external  wound,  either  persistently  or  intermittently  accord- 
ing to  the  low  or  high  location  of  the  opening.  The  last  two  symptoms 
are  of  great  diagnostic  value,  though  the  presence  of  blood  may  be  con- 
sequent upon  contusion  of  the  l)ladder  or  upon  wound  of  some  other  jiart 
of  the  urinary  tract,  and  leakage  of  urine  may  j)ossil)ly  come  from  lesion 
of  an  ureter  or  the  urethra,  and  whatever  its  origin  it  is  actually  met 
witli  in  Itut  a  limited  portion  of  the  cases  of  wounds  caused  by  pistol  or 


510  GUNSHOT  WOUNDS. 

small-calibre  rifle  balls.  When  there  is  an  associated  opening  of  the 
rectum  fecial  matter  may  be  discharged  with  the  urine  or  the  urine 
passed  through  the  anus.  Voluntary  micturition  may  be  possible  or 
catheterization  re(|uired  ;  in  the  latter  case  it  is  advantageous  for  every 
reason  to  keep  tiie  catheter  in,  rather  than  to  introduce  it  at  stated 
periods  or  as  necessary.  Sometimes  so  much  blood  accumulates  in  the 
bladder  that  aspiration  will  have  to  be  done.  When  there  has  been  dis- 
charge of  urine  into  the  abdominal  cavity,  certainly  in  any  considerable 
amount,  symjitoms  of  peritonitis  or  of  grave  septicemia  are  ra})idly 
developed,  the  latter  at  times  so  quickly  latal  that  upon  autopsy 
no  evidences  of  inflammation  are  to  be  seen.  Left  to  itself,  a  case  of 
this  kind  is  certain  to  die.  When  urine  is  extravasated  into  the  con- 
nective tissue  in  front  of  the  bladder  or  into  the  meshes  of  the  recto- 
vesical fascia,  abscesses  soon  form  or,  by  contiguity,  peritonitis  is 
induced.  The  progress  of  these  cases  of  bladder-wounds  illustrates 
the  truth  of  Bichat's  declaration  that  "  urine  is  the  most  baleful  fluid 
in  the  economy;"  if  not  so  when  of  normal  quality,  tuKpiestionalilv  so 
when  in  the  presence  of  blood  and  air  it  has  become  se})tic. 

Treatment  varies  as  the  lesion  is  intra-  or  extra-peritoneal.  In  the 
latter  case  a  catheter  may  be  introduced  and  retained  and  the  patient 
treated  exjiectantly.  But  unless,  from  the  location  of  the  wound  or 
wounds  antl  the  direction  of  the  shot,  it  is  very  certain  that  the  injury  is 
outside  of  the  peritoneum,  laparotomy  should  be  done  at  once,  the  abdom- 
inal cavity  cleansed,  and  the  wound  in  the  bladder  stitched  ;  and  if  there 
is  any  doubt  about  the  nature  of  the  injur}-,  su])ra])ubic  section  should  be 
made  and  the  prevesical  space,  if  not  the  abdominal  cavity,  opened  up^ 
Any  wound  should  be  stitched,  the  parts  cleaned  and  disinfected,  and 
drainage  secured,  preferably  by  a  gauze  plug.  If  a  foreign  body,  ball  or 
bone,  has  lodged  in  the  bladtler  (and  such  loilgement  has  taken  place  in  a 
disproportionately  large  number  of  vesical  wounds),  it  should  be  removed 
at  once  if  a  laparotomy  or  a  suprapubic  section  has  been  done,  otherwise 
it  may  be  taken  away  through  a  perineal  opening  either  early  or  after 
the  wound  in  the  bladder  has  healed.  Occasionally  there  has  been  an 
extraordinary  tolerance  for  months  or  years  of  the  foreign  body.  In  a 
number  of  cases  the  ball  or  Ijone,  or  even  a  piece  of  cloth,  in  the  Ijladder 
has  served  as  a  nucleus  upon  which  the  phos})hates  have  been  deposited 
and  stone  formed.  When  the  ball  has  been  lodged  externally,  it  has 
been  known  to  ulcerate  its  way  into  the  bladder  after  a  time,  years  even, 
and  then  require  removal ;  and  the  same  has  been  true  of  pieces  of  bone, 
fragments  detached  at  the  time  of  the  injury  or  later  separated  by  necro- 
sis. Otis  reported  twenty  lithotomies  done  on  account  of  such  injuries 
received  during  our  late  war.  Very  small  balls  have  at  times  been 
spontaneously  discharged  through  the  urethra. 

In  the  beginning  of  the  treatment,  whether  operative  or  otherwise  it 
matters  not,  fluids  should  be  given  very  sparingly.  Rest  as  absolute  as 
possible  should  be  maintained.  Any  abscess  that  can  be  located  should  be 
promptly  opened.  In  favorable  cases  healing  may  be  expected  to  take  place 
in  from  three  to  six  weeks.  In  many  of  the  cases  heretofore  observed 
in  time  of  war  in  which  death  did  not  speedily  follow,  recovery  was  very 
protracted  and  imperfect,  bone-sinuses  or  urinary  fistulae  remaining ; 
but  such  sequelae  are   not  likely  to  be  frequently  met  with  hereafter, 


WOUNDS  OF  REGIONS.  511 

in  either  military  or  civil  life,  because  of  the  changes  both  in  missiles 
and  in  treatment,  especially  the  latter. 

Genital  Organs. — Injuries  of  these  organs,  rare  in  civil  life,  not 
very  uncommon  in  military  practice,  may  be  either  superficial  or  deep ; 
occasionally  they  are  contusions,  generally  penetrating  or  perforating 
wounds,  in  a  few  instances  extensive  destructions.  Associated  injury 
of  tiiigh  or  abdomen  is  of  frequent  occurrence,  and  to  such  complication 
death,  wher.  it  takes  place,  is  usually  due  (of  1152  wounds  in  our  war, 
144  died— 12.5  per  cent.). 

Superficial  wounds  of  the  penis  or  scrotum '  are  injuries  of  little 
gravity  and  require  no  special  treatment,  any  produced  hajmatocele  or 
hernia  of  the  testis  (conditions  at  times  observed)  differing  in  no  respect 
from  that  consequent  upon  ordinary  traumatisms.  Occasionally  there 
has  been  lodgement  of  a  ball,  even  of  large  size,  under  the  skin,  the 
removal  of  which  has  been  easy ;  in  certain  cases  in  which  it  has  not 
been  taken  out  it  has  become  encapsulated  and  remained  harmless  for 
years,  though  its  presence  is  likely  to  be  troublesome. 

The  corpora  cavernosa  when  perforated  always  show  considerable 
laceration,  and  the  same  is  true  of  the  glans  penis.  A'ery  generally  the 
urethra  also  is  torn,  in  which  case,  unless  proper  treatment  is  pursued, 
urinary  infiltration  and  abscess  are  apt  to  be  produced.  As  late  results 
of  these  wounds  of  the  penis  there  have  been  seen  troublesome  and 
deforming  cicatricial  contractions  of  the  organ,  strictures,  and  fistulas, 
penile,  scrotal,  or  perineal  according  to  the  location  of  the  wound. 

Primary  treatment  has  reference  to  the  arrest  of  hemorrhage,  the 
securing  of  jirompt  closure  of  the  wound,  and  the  prevention  or 
relief  of  urinary  retention.  Bleeding,  which  is  apt  to  be  quite  free, 
may  be  controlled  by  the  stitching  of  the  edges  of  the  wound  together, 
by  ligation  of  any  divided  vessel  seen,  or  by  pressure,  a  catheter  being 
introduced  and  a  bandage  applied  around  the  organ.  Protecting  the 
wound  from  infi'ction  by  the  use  of  an  ordinary  antiseptic  dressing  will 
commonly  secure  its  prompt  healing.  To  prevent  urinary  disturbances 
(retention  or  infiltration)  the  bladder  must  be  kept  empty  by  a  retained 
catheter,  the  edges  of  the  urethral  laceration  being  stitched  over  it  if 
practicable,  or  if  the  loss  of  substance  has  been  great  the  M'ound  allowed 
to  close  by  granulation.  Much  benefit  will  often  follow  perineal  section 
and  the  turning  of  the  urine  through  such  ojiening. 

No  matter  how  much  the  penis  may  have  been  damaged,  it  is  ordi- 
narily unwise  to  amputate  ;  any  part  of  it  that  can  be  saved  should  be 
saved.  If  the  entire  organ  has  been  carried  away,  the  urethra  should 
be  dissected  back  and  a  new  meatus  established  in  the  perineum  if  the 
patient's  general  condition  permits  of  the  operation. 

In  other  than  the  most  su))eificial  wound  of  the  scrotum  the  testis  or 
cord  may  be  expected  to  be  injured  ;  in  a  tiiird  of  the  cases  studied  by 
Fischer  both  testes  were  struck.  The  damage  done  the  gland  liy  a  l)ullet 
except  at  short  range  is  rarely  such  as  to  necessitate  its  removal.  Hernia 
of  the  testis,  formerly  often  seen  in  cases  of  lesion  by  a  large  ball,  is 
very  unlikely  to  follow  pistol  shots  or  wounds  by  the  new  bullet,  but 
atrophy  of  the  organ  has  been  frequently  noticed,  as  has  more  or  less 
persistent,  and  often  intense,  neuralgia.  Antisepticallv  treated,  supi)ura- 
tion  ought   not  to  occur — a  complication  that  until  lately  was  almost 


512  GUNSHOT   WOUNDS. 

certain  to  lie  developed.  A\^hen  Ixjth  testicles  have  been  disorganized 
they  should  be  removed,  and  the  wound  closed  by  a  short  scrotal  flap  if 
there  is  enough  healthy  tissue  left  to  allow  of  its  formation. 

Wounds  of  the  female  genitals  are  rare,  and  they  are  usually  in  asso- 
ciation with  grave  abdominal  or  pelvic  lesions.  In  the  very  infrequent 
cases  in  which  they  are  inflicted  at  very  short  range  the  laceration  that 
takes  place  is  extensive.  In  a  case  personally  observed  in  which  the 
nuizzle  of  the  pistol  Mas  thrust  between  tlie  Ial)ia  the  combined  effect  of 
the  bullet  and  the  gases  of  explosion  was  to  destroy  almost  comjjletely 
the  vagina  and  the  uterus.  A  ball  passing  through  the  unimpregnated 
uterus  ordinarily  does  comparatively  little  harm,  but  where  pregnancy 
exists  there  is  much  risk  of  an  early  fatal  termination  from  aljortion 
(almost  certain  to  take  place),  from  hemorrhage,  from  shock,  or  from 
septic  inflammation.  In  certain  cases  which  have  survived,  flstula  has 
been  noticed,  giving  passage  to  the  menstrual  fluid  for  a  time  or  perma- 
nently. 

Sword  and  Bayonet  Wounds. 

Wounds  of  this  character  have  been  rarely  seen  in  recent  times — .37 
per  cent,  only  of  the  grand  total  of  wounds  in  LSfJl-Oo,  1.3  per  cent,  in 
1870-71,  .9  per  cent,  in  all  the  wars  from  the  Crimean  to  the  Franco- 
German,  both  included  (437,636-4890).  They  must  probably  be  much 
less  frequent  in  future  military  operations  ;  the  new  magazine  rifle,  that 
M'ill  disable  if  not  kill  at  a  mile,  a  mile  and  a  half,  or  two  miles'  distance, 
p^e^■enting  any  considerable  force  of  either  infantry  or  cavalry  apj)roach- 
ing  sufticiently  near  to  use  bayonet  or  sabre.  Surgeons  hereafter  will,  as 
a  rule  having  few  exceptions,  see  these  injuries  only  as  they  may  result 
from  individual  quarrels  or  in  mob-fighting.  As  made  by  the  bayonet, 
and,  much  less  often,  by  the  straight  sword,  the  wounds  are  j^imctured ; 
by  the  sabre,  when  sharp,  incised,  when  with  dull  edge,  as  it  generally 
is,  lacerated  and  contused.  The  bayonet  injuries  are  more  common  in 
the  lower  extremities  than  elsewhere  (46  per  cent,  of  the  whole  number 
reported  in  1861-65),  sabre  wounds  in  the  head  and  upper  extremities 
(89  per  cent,  in  the  same  war),  though  the  proportionate  local  frequency 
has  been  quite  different  in  different  wars.  Leaving  out  of  consideration 
cases  dying  on  the  field,  the  mortality-rate  is  low ;  with  us  it  was  7.7  per 
cent,  for  the  bayonet  and  5  per  cent,  for  the  sabre  wounds,  the  fatal  cases 
being  very  largely  those  in  which  one  or  other  of  the  great  cavities  was 
opened;  of  the  712  cases  in  which  they  were  not  ojiened  only  16  died 
(2^  per  cent.).  Aside  from  visceral  lesions  and  injuries  to  the  large  ves- 
sels, the  chief  danger  of  the  penetrating  M'ounds  is  in  the  damming  up 
of  fluids  in  their  depths  and  the  develojiment  of  su]>purative  inflam- 
mations ;  the  chief  danger  of  the  contused  and  lacerated  wounds  is  the 
occurrence  of  septic  conditions. 

The  appearance  of  the  wound  varies  as  it  is  made  by  thrust  or  by 
cut,  the  former  being  in  form  slit-like,  triangular,  or  more  or  less  cres- 
centie  according  to  the  shape  of  the  weapon  ;  the  latter  sho^Wng  a  straight 
cut  with  more  or  less  contusion  and  laceration  of  the  edges,  or  the  forma- 
tion of  a  flap,  or  an  ovoid  somewhat  tnipped  open  wound  from  complete 
or  nearly  complete  detachment  of  a  flap,  \vhich  latter  in  injuries  of  the 
cranium  may  have  in  it  a  piece  of  the  skidl  of  thickness  according  to  the 


A  BROW   WOUNDS. 


-513 


depth  of"  the  wound.     In  wounds  involviufj  tlie  kirynx,  trachea,  or  hnig 
empliy.sema  is  often  present,  it  may  be  in  higli  degree. 

The  treatment  is  tiiat  of  lesions  of  like  character  otherwise  produced. 
By  thorough  cleansing  and  proper  dressing  an  aseptic  condition  may 
generally  be  secured.  Vessel-wounds  will  necessitate  the  application  of 
ligatures  or  not  according  to  circumstances.  Detached  bone-fragments 
will  have  to  be  taken  away.  If  there  is  puncture  of  the  skull,  trephin- 
ing should  be  done.  Any  foreign  body,  clothing,  hair,  or  other,  that  may 
happen  to  have  been  carried  in  should  be  removed  if  its  presence  can  be 
detected,  clothing  being  especially  likely  to  be  lodged  in  the  seton  wounds 
of  the  soft  parts.  An  existing  emphysema,  if  it  does  not  soon  subside 
spontaneously,  will  necessitate  puncture. 

Arrow  Wounds. 

Once  so  common,  arrow  wounds  are  now  seen  extremely  rarely,  and 
hereafter  their  consideration  will  have  but  an  historic  value,  since  among 
other  tlian  the  lowest  and  most  isolated  tril)es  of  savages  firearms  have 
taken  the  place  of  the  bow.  As  met  M'itli,  they  were  of  tiie  nature  of 
both  punctured  and  incised  wounds,  penetrating,  even  perforating,  the 

Fig.  35. 


Skull  with  arrow-head  fixed  in  it.  taken  from  mound  in  Boone  Co.,  Ky. :  .1.  stone  arrow-head 
lodged ;   B,  injury  accidentally  done  by  pick  at  time  of  removal. 


body,  their  tracks  th;-ough  the  tissues  straight  and  clean  cut,  with 
entrance  wounds  somewhat  brui -ed  and  di.scolored  from  extravasated 
blood,  and  exit  ones  (if  present)  mere  slits.  Within  a  range  of  one 
hundred  yards  or  less  their  force  of  penetration  might  be  very  great, 
depending  of  course  upon  the  strength  and  skill  of  the  bowman. 
Often  an  arrow  was  sent  through  the  body  of  an  animal  as  large  as  the 
buffalo,  bone  being  ])ierced  as  with  the  point  of  a  large,  strong,  shttrj) 
knife.  Striking  a  blood-ve.ssel,  a  nerve-trunk,  or  an  intestine,  such  part 
could  not  glitle  out  of  the  way,  but  was  certain  to  be  wounded.  Severe 
Vol.  I.— 33 


514  GUNSHOT  \vuryi>s. 

hcniorrliafjo  was  likoly  to  occur.  The  ujiper  pai't  of  tlic  body  was  much 
uiore  ot'teu  injured  than  tlie  lower,  and  visceral  wounds  were  of  course 
niucii  tiie  nioi'c  daniicrous.  ThoutJcli,  as  has  been  stated,  tiie  course  of  the 
arrow  was  straigiit,  when  tiie  luad  was  of  iron  and  tiiin  it  at  times  upon 
striking  a  bone  bent  itself  around  it.  From  tlie  nature  of  tiic  missile 
and  the  almost  necessarily  unhygienic  surroundings  of  the  patient,  these 
wounds  were  in  great  measure  infected  ones;  and  so  nuich  of  the  mor- 
tality following  them  as  was  not  due  to  loss  of  blood  was  conse(|Uent 
u])on  se])sis.  When  the  head  iiad  lodged,  it  was  taken  out  whenever  it 
was  practicalile  to  do  so,  as  if  left  it  was  certain  to  cause  trouble.  Such 
extraction,  when  it  was  separated  from  the  shaft,  was  often  iliHicult  both 
in  the  seizing  and  removing.  Snares  and  forceps  of  different  kinds  were 
employed  to  facilitate  the  operation,  an  excellent  instrument  which  com- 
bined the  (pialities  of  both  snare  and  forceps  having  been  <levised  by  the 
late  Dr.  J.  H.  Bill.  To  him,  a  distinguished  officer  of  our  army  who 
had  a  long  service  with  troops  in  the  "  Far  West,"  Me  are  indel)ted  for 
much  information  respecting  the  nature  and  effects  of  arrow  injuries. 
In  concluding  his  article  in  the  Intcniatiorial  Encyclopaedia  of  Surgery 
upon  this  subject  he  sums  up  his  views  in  the  fc)llowing  words : 

"  (1)  An  arrow-head  nuist  be  removed  as  soon  as  found. 

"(2)  In  the  search  tiir  the  arrow  extensive  incisions  are  justifiable. 

"(3)  An  arrow  may  l)e  pushed  out  as  well  as  plucked  out. 

"(4)  The  linger  should  be  used  for  exploration  in  preference  to  a 
probe. 

"  (5)  Great  care  must  be  taken  to  avoid  detachment  of  the  shaft. 

"(6)  Healing  by  first  intention  should  be  enccturaged. 

"(7)  The  surgeon  should  strive  to  comfort  the  ]wtient.  Although 
arrow  wounds  are  not  attended  with  nuieh  shock,  they  are  usually  the 
cause  of  great  dejiression  of  spirits.  The  constitutional  disturliances 
following  these  wounds  ....  arc  liable  to  be  out  of  all  proportion  to 
the  apparent  amount  of  damage.  There  are  almost  ahvays  consider- 
able sleeplessness  and  great  irritability,  dejection  of  s])irits,  and  intol- 
erance of  pain.  The  tendency  to  despondency  becomes  frequently  a 
prominent  symptom,  to  be  carefully  combated,  and  ever}-thiug  should 
be  done  to  cheer  the  patient." 


FRACTURES. 

By  FEEDERIC  S.  DENNIS,  M.  D. 


A  FRACTURE  is  a  solution  in  tlie  contiiiuity  of  liono  or  cartilage,  pro- 
duced l)v  violence,  muscular  action,  or  disea*'.  The  word  "fracture" 
is  derived  from  the  Latin  verb f ran c/o,  meaning  "to  bi'eak."  Epiphys- 
eal separation  is  also  classed  with  fracture,  because  the  injury  is  pro- 
duced by  the  same  causes,  presents  the  same  signs,  and  retjuires  tlic  same 
treatment.     Fractures  may  be  coinpfctc  or  incomplrfc. 

Complffr  frnctuvex  are  su1)divided  into  sim|)lc,  compound,  ciimmi- 
nuted,  multiple,  complicated,  and  impacted.  Some  of  these  varieties  may 
again  be  subdivided,  according  to  the  direction  ol'  the  fracture,  into 
oblique,  transver.se,  longitudinal,  and  dcntated. 

IncQinpIde  fractures  may  be  subdivicled  into  greenstick,  jtartial,  fis- 
sured, stellate,  and  spiral. 

EpiphjiKcal  >iCjtariitioii  may  be  considered  as  a  species  of  fracture, 
since  tlie  injury  involves  a  tearing  away,  by  a  sudden  act  of  violence,  of 
the  epi])hysis  from  the  diapiiysis  of  the  bone,  the  separation  occurring  at 
the  cartilaginous  line  of  union.  This  injury  is  found  only  in  persons 
under  twenty-one  years  of  age,  since  after  that  ])eriod  the  epi]iliyses  are 
usually  united  l)y  bone  to  the  diaphyses.  The  rejiair  is  effected  l)y 
osseous  tissue,  and  as  a  result  the  bone  ceases  to  develo])  at  the  fractured 
end.  Shortening  occurs,  which  may  be  very  great  if  tlie  patient  at  the 
time  of  the  injury  has  not  attained  his  or  her  full  height. 

A  complete  fracture  is  one  which  entirely  traverses  the  bone.  A 
simple  fracture  is  one  in  which  the  bone  is  broken  at  one  point  and  the 
seat  of  fracture  lias  no  comnuuiication  with  the  external  air. 

A  compound  fracture  is  one  where  the  bone  is  liroken  at  one  or 
m()re  points  and  the  seat  of  fracture  has  comnuuiication  with  the  exter- 
nal air.  A  compound  fracture  must  not  lie  mistaken  for  a  simple  frac- 
ture attended  by  a  wound  in  the  soft  parts.  In  the  former  case  the 
wound  is  the  result  of  the  fra(  ture,  and  comes  from  within,  while  in 
the  latter  case  the  wound  is  ind('|)cndcnt  of  the  fracture,  and  comes 
fnini   without. 

A  commhiiili'd  fracture  is  one  in  which  the  bone  is  broken  into  niaiiv 
small  fragments  (Fig.  .'}()). 

Amultijile  fracture  is  one  in  which  several  liactui'es  occur  in  the  .same 
bone  (Fig.  37). 

A  complicated  fracture  is  one  which  is  associated  with  a  wound  ojwn- 

515 


516 


FRACTURED 


ing  into  a  joint,  or  is  accompanied  by  an  injury  to  an  internal  organ,  to 
an  artery,  or  to  a  nerve,  or  wiiich  coexists  with  a  dislocation. 


Fr«.  3H. 


CinuininutL'd  fracture  of  tibia  and  filmla. 


An  impacted  fracture  is  one  in  which  tiie  fragment  consisting  of 
compact  bone  is  driven  into  the  fragment  of  cancellated  bone  (Fig.  38). 


Fig.  37. 


Multiple  fracture  of  both 
bones  of  the  leg. 


Fig.  38. 


Impacted  fracture  of  the  neck  of  the 
femur. 


Fractui'es  may  l)e  subdivided  again  according  to  the  direction  of  the 
line  or  plane  of  separation. 

An  oblique  fracture,  which  is  the  most  common  form,  is  one  in  which 
the  line  of  separation  is  at  an  acute  angle  to  the  long  axis  of  the  bone 
(Fig.  39).     A  tranm-crse  fracture  is  one  in  which  the  line  of  separation 


DEFINITIONS. 


517 


is  at  a  riglit  angle  to  tlic  loiiii'  axis  of  the  bone.     This  variety  is  found 
chiefly  in  children  and  seldom  in  adults. 

A  longitudinal  fracture  is  one  in  which  the  line  of  separation  is  par- 
allel to  the  loner  axis  of  the  bone. 


This  variety  is  rare,  and  is  usually 
associated  with  gunshot  injuries 
(Fig.  40). 

A  dentatcd  fracture  is  one  of 
such  a  character  that  the  oppos- 
ing surfaces  denticulate  with  each 
other,  so  that  the  projections  of 
one  fragment  tit  into  the  depres- 
sions of  the  other  fragment. 

An  incomplete  or  partial  frac- 
ture is  one  which  only  partially 
traverses  the  bone,  as  in  a  fracture 
of  the  external  table  of  the  skull 
while  the  internal  table  remains 
intact. 

Fig.  39. 

lli!V 


Fio.  40. 


Oblitjiie  fracture  of  the  humerus. 


Longitudinal  fracture  of  femur. 


A  greenstick  fracture  occurs  when  the  bone  merely  bends.  In  this 
fracture  a  portion  of  the  fibres  are  broken,  while  the  remainder  hold  the 
bone  intact  (Fig.  41).  This  may  occur  as  an  intra-uterine  fracture  when 
the  soft  bones  of  the  fcetus  are  bent  as  a  result  of  alinormal  uterine  eon- 
tractions,  or  by  external  violence,  as  in  consequence  <jf  a  fall  experienced 
by  the  parturient  woman. 


518 


FRACTl'RES. 


Fig.  41. 


A  fimurcd  fnirfurr  is  one  in  wlii(-ii  a  linear  divison  has  occurred 
without  any  displacement.  This  variety  is  seen  in  tiie  skull,  especially 
over  the  vertex. 

A  .stellate  fracture  is  one  Avhieli  radiates  from  a  cen- 
tral axis,  somewhat  after  the  shaj)e  of  a  star.  This 
variety  is  seen  chiefly  in  the  skull,  although  occasionally 
it  occurs  in  long  bones,  like  the  i'cnuu-,  after  a  iiiinshot 
injury. 

A  .spiral  fracture  is  one  in  which  the  line  of  the 
break  assumes  a  spiral  course.  This  variety  is  seen 
in  the  bones  of  the  cranium,  but  it  is  also  occasionally 
observed  in  the  long  bones  (Figs.  42  and  43). 

A  r/un.sJwt  fracture  is  one  in  which  the  Ixme  is  broken 
as  a  result  of  a  gunshot  wound.  This  special  \ariety  of 
fracture  may  be  either  complete  or  incomplete. 

Etiology  of  Fractures. — The  causes  of  fracture  are 
prcdi.sjio.siu;/  and  e.rcitiiuj.  The  former  include  all  cir- 
cumstances which  tend  to  make  the  bone  more  brittle, 
while  the  latter  include  all  actual  or  direct  forces  cau.sing 
the  injurv.  If  a  bone  fractures  without  any  apparent 
p.iitiai  or  green-  excitiug  causc,  it  is  Said  to  be  a  spontaneous  fracture. 
the 'rad'ius^''^  "^  AuioHg  the  predisposing  causes  may  be  mentioned  the 
influence  of  age,  since  the  tendency  to  fracture  increases 
as  age  advances.  This  is  because  the  bones  in  the  aged  are  less  elastic 
and  more  brittle  as  a  result  of  the  loss  of  organic  matter,  and  at  the 
same  time  the  muscles  have  lost  a  ceitain  amount  of  their  elasticity. 


Fig.  42. 


Fig.  13. 


Sex  is  another  predisposing  cause,  since  fractures  are  fomid  more  fre- 
quently in  the  male,  with  the  exception  of  the  intra-capsular  fracture  of 
the  neck  of  the  femur.  This  is  due  to  the  foct  that  the  female  is  less 
active  and  less  exjxised  to  violence. 

Season  is  a  predisposing  cause,  since  in  winter  fractures  are  much 
more  frequent  than  in  summer.     Tliis  may  be  due  to  the  presence  of  ice, 


ETTOLOar. 


519 


■\vliicli  increases  the  lialiility  to  l)i)(lily  falls,  and  also  because  the  muscles 
are  supposed  to  be  less  elastic  in  eokl  weatlier. 

The  liabiliU/  of  certain  bones  to  fracture  may  be  considered  a  predis- 
]iosing  cause,  since  the  bones  upon  the  right  side  of  the  body  are  more 
frc([uently  fractured  than  those  upon  the  left  side.  This  is  due  to  the 
tact  that  the  right  side  of  the  body  is  used  more  tlian  the  left  for  the 
])urposes  of  attack  and  defence.  The  bones  Ibrming  the  trunk  are  less 
frequently  broken  than  those  of  the  upper  extremity,  and  the  bones 
of  the  up|)cr  extremity  less  frequently  than  those  of  the  lower  ex- 
tremity. Again,  the  long  bones  are  more  frequently  broken  than  the 
short  bones.  The  two  individual  bones  which  are  most  susce])tible  to 
fracture  are  the  clavicle  and  the  radius.  As  to  the  relati\-e  frequency  of 
fractures  attcctiug  the  ditfcrent  bones,  Ourlt's  tal)le  is  here  introduced,  a 
studv  t)f  which  affords  some  valuable  intbrmation  : 


Fractures  treated  in  the  London  ITospitals,  1843-77,  Archiv.  f.  kiiii.  CIdr.,  xxv.,  1880,  p.  469. 


Skull  .  . 
Faoe  .  . 
Spine 
Pelvis  . 
Coccyx  . 
Ribs  .  . 
Stern  lira 
Scipula . 
Clavicle 
Arm  .  . 
Forearm 
Hand  . 
Tliish  . 
Patella  . 
Leg  .  . 
Foot  .   . 


In 

Hospital. 


730 
732 
169 
139 
5 

4784 

4.5 

135 

382 

1064 
709 
856 

3072 
649 

8067 
965 


22,503 


Out-patients. 


27 

513 

3 

3 

10 

3477 

7 

290 

74.58 

3020 

8731 

4S99 

171 

15 

256 

555 


29,435 


Total. 


757 
1245 

172 

142 

15 

8261 

52 

425 
7840 
4084 
9440 
5755 
3243 

664 
8323 
1520 


Per  cent. 


1.457 
2.397 
0.331 
0.273 
0.028 

15.905 
0.1 
0.818 

1.5.094 
7.863 

18.175 

16.080 
6.243 
1.278 

16.024 
2.926 


Head,  2002 ; 
3.854  per  cent. 


Trunk,  9067  ; 
17.457  per  cent. 


Upper  cxtremiti/,  27,119 ; 
52.214  per  cent. 


Lower  extremity,  13,750 ; 
26.473  per  cent. 


51,938 


Certain  diatheses  are  predisposing  causes  of  fracture,  including  the 
results  of  such  diseases  as  syphilis,  cancer,  sarcoma,  rickets,  scrofula, 
rheumatism,  gout,  mollitics  ossium,  and  mercurialization.  Fatty  degen- 
eration and  senile  atrophy  arc  conditions  favorable  to  the  production  of 
fracture. 

The  (Writing  causes  of  fracture  are  indirect  violence,  direct  violence, 
and  muscular  contraction,  which  are  mentioned  in  the  order  of  fre- 
quency. 

In  indirect  violence  a  force  is  applied  to  two  parts  of  a  bone,  and  a 
fracture  occurs  between  the  two  points  of  violence. 

In  direct  violence  a  force  is  a])plic(l  to  a  certain  part  of  the  bone,  and 
at  the  point  of  impact  a  fracture  occiu-s.  Tiie  results  of  fractiu-e  by 
direct  violence  are  more  serious  than  those  by  indirect  violence,  since 
here  is  the  additional  injury  inflicted  upon  the  soft  parts,  and  sometimes 
injury  to  important  organs. 

Jrn.'<cul(ir  contraction  is  the  rarest  cau.se  of  fracture,  taken  as  a  whole, 
although  in  certain  individual  bones  it  is  most  frecpicnt.  The  special 
bones  which  are  most   fre(|uiiitly  the  scat  of  fracture  by  muscular  con- 


520  FRACTURES. 

traction  arc  tlic  os  calcis,  tiliia,  patella,  rcnim-,  olecranon  ])roccss  of  ulna, 
liiiincrus,  an<l  (daviclc. 

Repair  of  fractures  is  considered  in  the  article  on  Surgical  Pathology, 
and  the  reader  is  referred  to  it  for  information  u])on  this  important 
subject. 

Symptoms  and  Signs  of  Fractures. — There  is  occasionally  a  slight 
rise  of  tenijtcrature  following  the  recei])t  of  a  fracture,  hut  the  elevation 
is  of  no  special  significance.  A  chill  sometimes  occurs,  hut  it  is  nervous 
and  not  septic  in  charac^ter,  and  is  of  no  s])eeial  importance.  Shock  also 
often  accompanies  a  fracture,  but  this  condition  soon  passes  away  unless 
the  fracture  is  compound  or  com])licated. 

The  first  sign  of  fracture  consists  of  unnatural  mobility,  or  the  exist- 
ence of  a  false  or  abnormal  point  of  motion,  which  is  present  except 
in  the  impacted  variety  or  M'lierc  the  fracture  involves  certain  bones, 
as  the  skull  or  the  body  of  a  vertebra.  There  are  different  methods 
of  ascertaining  the  presence  of  a  false  point  of  motion.  In  fracture  of 
the  fibula  or  radius  both  hands  should  envelop  the  limb,  with  the 
thumbs  placed  over  the  suspected  site  of  fiacture.  The  alternate 
pressure  of  the  thumbs  will  cause  the  fragments  to  s|iriug  out  beyond 
each  other.  In  fracture  of  the  tibia  it  is  best  to  hold  tirndy  the  upper 
fragment,  and  then  move  the  lower  one.  In  fracture  of  the  ribs  or  of 
the  sternum  the  palm  of  the  hand  can  be  placed  over  the  thorax  and  the 
patient  requested  to  cough.  In  case  of  fracture  of  the  thigh  or  humerus 
rotation  of  the  limb  will  demonstrate  a  false  point  of  motion.  The  nearer 
the  fracture  is  to  the  centre  of  the  bone,  the  greater  the  mobility.  The 
mobility  is  passive  in  character,  and  not  active. 

Another  sign  consists  of  rotary  displacement  of  the  limb,  caused 
chiefly  by  its  weight,  by  muscular  contraction,  and  by  the  violence  pro- 
ducing the  fracture.  In  estimating  the  displacement  careful  inquiry 
should  be  made  to  ascertain  if  any  ])revious  deformity  existed.  The 
amount  of  displacement  is  often  influenced  l)y  the  direction  of  the  frac- 
ture in  the  bone. 

Still  another  sign  is  angular  deviation  from  the  normal  axis,  which  is 
especially  seen  in  the  impacted  variety  caused  by  great  violence.  It  is 
absent  if  one  only  of  two  bones  in  the  limb  is  broken  or  if  the  fracture 
is  longitudinal. 

Crepitus  is  a  pathognomonic  sign,  the  presence  of  which  can  be  deter- 
mined by  firmly  fixing  the  upper  fragment  and  moving  the  lower  one. 
In  certain  fractures — as,  for  example,  those  about  the  hip-joint — slight 
rotation  of  the  limb  will  serve  to  demonstrate  the  presence  of  this  al)so- 
lute  sign. 

When  crepitus  is  found,  it  is  an  nnecjnivocal  sign  of  fracture,  but  its 
absence  will  not  exclude  the  presence  of  fracture.  C'rejiitus  is  absent 
in  imjiacted  fractures,  in  cases  of  widely-seiiarated  fragments,  as  in 
fracture  of  the  jiatella  or  olecranon,  in  cases  where  blood-clots  or  fascia 
or  muscle  intervene  between  the  broken  ends  of  the  bones;  also  after 
a  few  days  following  the  injury,  at  which  time  the  fragments  are  covered 
l)y  inflammatory  exudations.  Finally,  crepitus  is  absent  in  the  green- 
stick  fracture  and  in  the  fractures  involving  the  cranial  bones.  There 
are  many  conditions  which  may  be  mistaken  for  cre])itus  ;  for  example, 
emphysematous  crackling  caused  by  the  presence  of  air  in  the  tissues, 


DIAGNOSIS.  521 

albuminoid  crepitation,  the  creaking  of  tendinous  sheaths  in  thecal 
inflammations,  joint  effusions,  and  bursitis,  the  grating-  of  osti'o])]iytes 
in  riicumatoid  artiiritis,  and  the  ])lcuritic  friction  caused  in  injuries  of 
the  chest.  The  use  of  tlie  stethoscope  lias  been  suggested  witii  a  view 
to  ascertaining  the  presence  of  crepitus  when  it  cannot  be  heard  by  the 
ear  or  felt  by  the  hand. 

The  presence  of  locntizcfl  pain  and  tenderness  and  of  ecchymosis  is  an 
important  link  in  the  chain  of  evidence.  The  tenderness  is  present 
immediately  upon  receipt  of  the  injury,  while  the  ecchymosis  is  not  well 
marked  until  a  few  days  after  the  occurrence  of  the  fracture.  The 
ecchymosis  is  due  to  a  hemorrhage  from  a  rupture  of  the  small  blood- 
vessels in  the  limb,  also  from  laceration  of  the  medulla  of  the  bone.  A 
mottled  appearance  after  a  fracture  indicates  that  the  source  of  the  blood 
is  from  the  medullary  cavity  of  the  bone.  The  ecchymosis  is  more 
ajiparent  when  the  fracture  involves  a  large  bone  or  when  the  fracture 
is  extensive  or  situated  close  to  the  skin.  If  the  extravasated  blood 
extends  and  causes  pressure  u]ion  the  synovial  capsule  of  a  joint,  so  as 
to  cause  irritation,  the  intra-articular  effusion  of  Gosselin  results.  The 
ecchymosis  may  spread  along  planes  of  muscles,  and  be  observed  at 
a  point  distant  from  the  seat  of  fracture.  This  clinical  fact  is  presump- 
tive evidence  of  the  existence  of  a  fracture,  provided  no  contusion  is 
present  to  explain  the  ecchymosis.  If  a  wound  of  the  soft  parts  exists 
near  a  fracture,  the  })resence  of  fat-globules  upon  it  or  in  the  blood 
indicates  the  origin  of  the  globules  from  the  medulla,  and  hence  this 
sign  is  pathognomonic  of  fracture. 

Shortening  of  the  limb  is  a  sign  of  fracture  when  it  involves  the 
extremities.  The  direction  of  the  fracture  influences  tiie  amount  of 
shortening.  A  fracture  of  tlie  obli([ue  variety  is  usually  attended  by 
shortening,  while  the  transverse  variety,  ()r  a  fracture  near  a  joint,  is 
seldom  accompanied  by  shortening.  The  amount  of  shortening  may 
be  from  one  to  three  inches,  and  in  estimating  the  amount  the  fact  of 
asymmetry  of  limbs  must  not  be  overlooked,  since  investigation  has 
demonstrated  that  oftentimes  there  is  a  variation  of  as  much  as  half 
an  inch  in  the  length  of  a  pair  of  unfractured  limbs.  There  are  a  few 
fractures— for  example,  of  the  ])atella  and  the  olecranon — wliere  length- 
ening instead  of  shortening  of  the  l)one  occurs. 

The  diag-nosis  of  fracture  is  attended  with  no  difficulty,  provided 
the  signs  of  displacement,  mobility,  and  crepitus  are  present.  Tiie 
diagnosis,  however,  may  be  extremely  difficult  if  inflammatory  swelliiig 
has  taken  place,  if  the  fracture  is  impacted,  if  its  situation  is  near  a 
joint,  if  only  one  of  two  parallel  bones  is  broken,  or,  Anally,  if  the 
break  traverses  the  Ixme  transversely.  In  these  obscure  cases  it  is 
better  to  defer  the  flnal  examination  luitil  it  can  be  made  under  the  influ- 
ence of  an  ansesthetic  and  when  everything  is  prepai'ed  to  adjust  some 
permanent  splint.  The  auiesthetic  should  not  be  employed  unless  the 
patient's  ])hysical  condition  justifles  the  use  of  this  measure  for  the 
purpose  <if  arriving  at  a  correct  diagnosis.  In  all  cases  of  doubt  tiie 
injury  should  be  treated  as  if  a  fracture  existed.  In  cases  where  a 
dislocation  coexists  with  a  fracture  amesthcsia  is  indicated,  since  by 
this  means  only  can  the  exact  diagnosis  be  established,  the  dislocation 
reduced,  and  the  fractured  bone  accurately  adjusted.     In  the  differential 


522  FRACTURES. 

<liagnosi.s  between  fraeture  and  disloeation  tlie  surgeon  must  not  over- 
look the  fact  that  in  dislcR'ation  tliere  is  no  shortening  of  tlie  shaft  of  tlie 
bone  or  false  point  of  motion  (jr  inmatural  niol)ility,  while  in  the  ease  of 
frai'ture  there  is  shortening  of  the  shaft  of  the  bone,  and  mobility  and 
a  false  point  of  motion  exist.  A  contusion  is  often  mistaken  for  a  frac- 
ture, but  the  absence  of  shortening,  bony  crepitus,  mobility,  and  disjilace- 
nient  serves  to  establish  the  ditt'erential  diagnosis. 

The  prognosis  of  fraeture  depends  upon  the  age,  sex,  and  general 
condition  of  tiie  patient,  as  well  as  upon  the  character  of  the  fracture 
and  the  special  form  of  apparatus  employetl.  A  compound  fracture  is 
nuich  more  serious  than  a  simple  one,  and  requires  three  times  as  long  to 
repair.  A  gunshot  fracture  is  the  most  serious  of  all  varieties,  and  the 
involvement  of  a  joint  adds  to  the  gravity  of  the  case.  An  oblique 
fracture  requires  twice  as  long  to  rcjiair  as  a  transverse  one. 

The  general  management  of  fractiu'cs  rccpiires  careful  consideration. 
Fractures  are  a  common  cause  of  trouble  between  the  patient  and  sur- 
geon. The  sui'geon,  to  protect  himself  against  a  suit  for  damages,  should 
exercise  great  care  in  the  treatment  of  the  fracture,  and  at  tlie  same 
time  possess  a  full  knowledge  of  the  pi'incijilcs  involved  in  tlie  manage- 
ment of  tlie  special  fractures.  The  tiirmcr  condition  re(piircs  constant 
and  untiring  attention  to  the  j)atient  ;  the  latter,  careful  study  and  ob- 
servation of  the  injury.  Wlien  these  two  conditions  are  fulhlled,  no  suit 
for  malpractice  can  be  sustained. 

The  examination  of  the  fracture  should  be  deferred  until  the  patient 
is  at  his  home.  The  j)atit'nt  sliould  at  once  Ite  jilaccd  u])on  a  wire  or  hair 
mattress  and  a  firm  bed,  but  never  upon  a  canvas  or  feather  bed.  An 
ordinary  hair  mattress  can  be  converted  into  an  excellent  fracture-bed  by 
placing  under  the  mattress  some  boards  sawed  the  j) roper  length,  to  take 
the  place  of  the  springs.  In  case  of  fracture  of  the  lower  extremity  the 
boots  or  slioes  should  be  cut  off  and  the  trousers  rip])cd  up  at  the  seam,  to 
avoid  any  unnecessary  movement  of  the  limb.  If  suitable  sjilintsare  not 
at  hand,  tlie  limb  can  be  ])]accd  in  a  fracturt^-box,  in  wliich  oakum  or 
bran  can  l)e  used  witli  great  advantage  as  a  tenqxirary  dressing.  A  most 
important  procedure  is  the  lifting  of  the  broken  limb.  This  should 
be  accomplished  for  the  lower  limb  by  the  surgeon  seizing  the  foot  near 
the  toes  with  Ins  right  hand  and  the  heel  witli  tiic  left  hand,  and  then 
making  slow  but  steady  extension  in  the  line  of  tlie  normal  axis  of  the 
linil).  After  full  extension  in  the  axis  is  acc<inq)lislied  tlie  entire  limb 
can  t)e  raised  to  any  height.  The  muscles  often  resist  the  surgeon,  who 
should  never  relax  his  extension,  since  by  so  doing  the  danger  of  pro- 
ducing a  compound  fracture  is  very  imminent.  The  extension  should 
never  l)e  suddenly  exercised,  but  slowly  and  uniformly,  and  always  in 
the  normal  axis  of  the  limb.  It  is  at  this  time  that  a  thorough  exam- 
ination of  the  fracture  can  be  satisfactorily  made,  and  its  exact  seat 
and  direction  and  its  tendency  to  disjilacemcnt  l)e  ascertained. 

In  making  extension  and  counter-extension  the  surgeon  must  avoid 
compressing  muscles  ])assing  over  the  fracture,  distribute  the  force 
over  a  large  surface,  and  extend  slowly  in  the  normal  axis  of  the  bone. 
Tliere  are  often  obstacles  met  with  in  attempts  to  employ  extension  and 
counter-extension,  among  wliich  may  be  mentioned  the  irregularity  of  the 
fracture,  interposition  of  nmst'lcs  and   tendons,  tonic  contraction  of  tlie 


COMPOUND  FRACTURES.  523 

muscles,  and  the  presence  of  s])linters  of  bone.  The  condition  of  shock 
often  enables  the  sui-geon  to  reduce  a  fracture  when  it  would  lie  otherwise 
impossible  to  accomplish  the  oljjcct  without  aiucstliesia.  The  tonic  con- 
traction of  the  nuisclcs  often  presents  an  insurmountalilc  barrier  to  tiie 
reduction  of  fractures  of  the  extremities.  It  is  of  little  use  to  employ  an 
anaesthetic  iu  these  cases,  and  the  only  sure  and  certain  way  to  ett'cct  a 
reduction  is  to  perform  tenotomy  for  any  or  all  muscles  which  resist. 
This  method  is  not  only  certain  to  ])ermit  of  the  easy  reduction  of  any 
fracture,  but  the  physiological  rest  thus  secured  to  the  fragments  is  most 
beneficial,  since  the  irritability  of  the  muscles  continues  unless  the 
operation  is  performed. 

After  the  reduction  of  the  fracture  is  accomplished,  the  next  object  to 
be  secured  is  the  retention  of  the  fragments  in  their  proper  place.  The 
accomplishment  of  this  object  is  olitaincd  by  suitable  apparatus  iu  tlie 
form  of  splints  or  bandages.  Occasionally  a  limb  is  covered  with 
phlyctenfe  or  blebs,  which  prevent  the  immediate  application  of  a  per- 
manent splint.  The  use  of  a  fracture-box  is  indicated  until  the  blebs 
disappear.  The  blebs  sliould  be  pnnctui'cd  with  a  clean  aseptic  needle, 
and  the  serum  thus  allowed  to  escape,  and  a  piece  of  non-irritating  but 
aseptic  gauze  should  be  placed  over  the  site  of  the  vesicle  for  a  few  days. 
In  the  forearm  a  bandage  should  never  be  placed  over  the  limb  in  eon- 
tact  witii  the  skin  and  under  any  splint,  since  it  may  cause  undue 
approximation,  or  even  fusion,  of  the  two  bones,  and  thus  prevent  the 
movements  of  pronation  and  supination.  If  any  tension  exists,  cotton 
should  be  wrajiped  around  the  limb  luider  any  s])lint,  since  the  inflam- 
matory swelling  will  tlien  less  endanger  the  limb,  as  the  cotton  yields 
and  adapts  itself  tu  the  varying  conditions  of  tension. 

(For  a  full  description  of  the  different  varieties  of  l)andages  and  their 
application  the  reader  is  referred  to  the  article  on  Mincn-  Surgery.) 

Compound  Fractures. 

Compound  fractures  require  immediate  and  prompt  attention.  The 
fate  f)f  a  ])atient  with  a  compound  fracture  often  Iiangs  upon  the  surgeon 
who  first  touches  it.  It  should  be  a  ruh;  of  practice  that  antiseptic  irri- 
gation should  be  employed  at  the  station-house  or  upon  the  sidewalk 
bef()re  the  temporary  sjjlint  is  adjusted,  and  that  at  once  after  the  irriga- 
tion a  clean  antiseptic  dressing  lie  applied  before  the  patient  is  lifte<l  into 
the  ambulance  to  be  carried  to  the  hospital  or  to  his  home.  If  no  anti- 
septic solution  can  be  olitained,  wash  tiie  wound  in  water  that  has  been 
raised  to  the  boiling-point  and  cooled. 

The  patient  having  been  carried  either  to  the  liospital  or  to  iiis  home, 
the  temjjorary  dressing  is  now  to  be  removed,  the  fracture  adjusted,  and 
the  first  dressing  ap])lied.  Too  much  emphasis  cannot  be  ])laced  upon 
the  point  that  the  firxt  and  axepflo  dreiixinf/  irill  lair/c/i/  iiitfiicticc  the 
prnr/jtosis.  Tliis  dressing,  therefore,  in  a  hospital  should  be  made  in  the 
operating-room,  because  tlie  germ-laden  air  of  the  hosjiital  ward  is  not 
a  safe  place  in  which  to  expose  a  compoimd  fracture.  The  instruments, 
sutures,  ligatures,  drainage-tubes,  and  everything  possibly  required  for 
the  operation  should  be  immersed  in  carbolic-acid  solution  (1:40). 
Several  towels  wrung  out  in  a  solution  of  bichlori<le  of  mercury  (1  :  500) 


524  FRACTURES. 

should  lie  ]ir(>]wrc(l  for  use  alioiit  the  table  and  around  the  limb,  in  order 
to  protect  the  wound  from  any  ])ossil)le  contaet  with  a  surface  not  ren- 
dered aseptic.  The  wound  itself  should  be  covered  by  antisc|)tic  jjauze, 
while  the  limb  is  washed  with  soap  and  water,  then  shaved  and  irrigated. 
Upon  the  limb  is  then  poured  a  saturated  solution  of  naphthalin  in  ether 
or  of  iodoform  in  ether.  This  application  removes  all  the  fat,  and  the 
naphthalin  or  iodoform  remains  as  a  layer  upon  the  surface  and  protects 
the  ]xirts. 

Having  made  aseptic  all  the  adjacent  |)arts,  the  wound  itself  requires 
attention.  All  blood  and  debris  shoidd  be  washed  away  by  a  stream  of 
warm  biehloride-of-mercury  solution  (1  :  4000).  The  interior  of  the 
wound  should  be  thorouohly  irrigated  with  the  same  solution,  and  all 
hemorrhage  completely  arrested.  Loose  pieces  of  bone  not  attached  to 
periosteum  should  be  removed.  The  fragments  can  now  be  adjusted, 
and  if  the  displacement  is  great  a  silver  wire  can  be  introduced  to  keep 
them  in  place.  Again,  it  may  be  necessary  to  introduce,  besides  the  wire 
through  the  bone,  some  deep  catgut  sutures,  which  are  carried  through 
the  muscles.  Deep  sutures  are  necessary  in  all  extensive  and  gaping 
wounds  of  the  soft  parts,  especially  when  such  uuiscles  as  the  biceps  and 
triceps  or  the  (juadriceps  extensor  are  divided.  These  sutures  must  be 
independent  of  the  superticial  set.  All  fragments  of  fascia,  fatty  tissue, 
muscular  shreds,  and  lacerated  integument  should  be  cut  aw'ay  with  scis- 
sors, and  then  a  final  ablution  made.  A  drainage-tube  should  be  intro- 
duced into  the  bottom  of  the  wound,  and  if  the  wound  is  so  situated  as  to 
drain  well,  there  is  no  necessity  for  a  counter-opening.  Such  wounds  as 
just  described  require  free  drainage,  and  couriter-openiug  may  be  neces- 
sary iu  order  to  meet  the  requirements  of  the  case.  The  tube  is  then 
cut  off  flush  with  the  surface  of  the  skin  and  fastened  by  a  safety-pin. 
The  wound  is  now  closed  by  catgut  sutures,  which  completes  the  opera- 
tive technique.  The  towels  should  now  be  changed  and  clean  ones 
substitutetl,  which  should  also  be  wrung  from  bichloride  solution.  This 
dressing  can  be  done  without  an  anicsthetic  and,  as  a  rule,  with  little 
or  no  pain.  When  the  compound  fracture  is  extensive,  it  is  necessary 
to  administer  ether,  so  that  the  dressing  can  be  completed  from  the 
beginning  to  the  end  while  the  patient  is  under  the  influence  of  an 
anaesthetic. 

A  class  of  eomjiound  fractui'cs  is  often  met  in  which  the  wound  is 
very  small,  and  with  these  cases  a  different  ]ilan  should  be  adopted.  The 
irrigation  should  l)e  made  around  and  iu  the  wound,  and  then  it  can  be 
hermetically  sealed  by  spriidiling  iodoform  upon  a  small  jiiece  of 
absorbent  cotton  and  ]>lacing  it  over  the  perforation,  and  painting  styptic 
collodion  over  it.  This  mixture  will  soon  coagulate,  the  medium  of 
sealing  is  surgically  clean,  and  then  the  fracture  is  ready  for  the  dress- 
ings. Thus  small  wounds  can  be  hermetically  scaled,  medium-sized 
wounds  closed  by  sutures  and  drained  through  the  existing  opening, 
and  large  wounds  tlrained  by  a  counter-opening  and  sewed  with  deep 
sutures,  and  the  fragments  held  together  by  silver  wire. 

Having  completed  the  0])erati\-e  technique  in  one  of  the  three  ways 
mentioned,  the  parts  are  now  prepared  for  the  antiseptic  dressings. 
Iodoform  gauze  or  a  small  piece  of  oil-silk  jtrotective  should  l)e  jdaced 
over  the  wound,  witii  a  hole  cut  in  it  to  allow  the  mouth  of  the  drainage- 


COMPOUND  FBACTUBES.  525 

tube  to  drain  into  the  dressings.  Iodoform  gauze  is  used,  because 
liirhloride  gauze  irritates  tiic  wound.  The  bichhiride  gauze  is  next 
applied  in  loose  pieces  over  the  iodoform  gauze  and  around  the  wound. 
This  dressing  is  moist,  because  dry  antiseptic  dressings  adjacent  to  a 
wound  are  sources  of  infection.  The  loose  and  wet  gauze  is  held  in 
situ,  by  the  application  of  a  moist  bandage.  Over  this  deep  dressing 
absorbent  cotton  is  placed  and  retained  by  a  dry  bandage. 

This  last  dressing  affords  a  means  of  securing  equable  and  uniform 
compression  around  the  liml)  and  over  the  fracture.  The  cotton  by 
its  elasticity  accommddates  itself  to  the  swelling  of  the  parts  in  the 
vicinity  of  the  fracture.  This  part  of  the  dressing  is  very  important 
as  a  means  of  preventing  inflammatory  swelling  and  of  affording 
comfort  to  the  patient.  Four  strips  of  sheet  iron  about  one  inch 
in  width  are  now  adjusted,  (^ne  strip  is  to  pass  down  on  the  pos- 
terior part  of  the  limb  and  over  the  heel  and  upon  the  sole  of  the  foot. 
Two  strips  are  placed  upon  the  sides  of  the  leg  and  one  v\\)^n\  the  front 
of  the  leg,  and  bent  so  as  to  conform  to  the  shape  of  the  dorsum  of  the 
foot.  Over  these  strips  plaster-of-Paris  bandages  are  now  applied,  and 
the  dressing  is  completed.  These  strips  ])revent  any  backward  as  well 
as  any  lateral  displacement  of  the  fracture,  and  also  do  away  with  the 
necessity  of  a  heavy  splint. 

In  three  days  a  fenestrum  is  cut  over  the  wound,  and  under  continuous 
irrigation  the  drainage-tube  is  removed. 

The  (juestion  of  how  long  this  first  dressing  should  remain  is  an  im- 
portant one.  Experience  has  taught  that  no  splint  shoidd  be  left  on  a 
limb  longer  than  eight  days  without  an  inspection  of  the  compound  frac- 
ture. The  author  has  seen  several  bad  restdts  arising  from  a  neglect  of 
this  rule.  In  one  case  a  fracture  which  was  skilfully  dressed  with  ])laster 
of  Paris  ^^'as  Hrst  examined  at  the  expiration  of  six  weeks,  during  \xhicli 
time  the  patient's  general  condition  was  in  every  way  satisfactory.  After 
removing  the  splint  the  bone  was  found  protruding  and  considerable 
luiion  had  taken  place.  An  osteotomy  corrected  tiic  (k^formity,  and  in  six 
additional  weeks  a  perfectly  satisfactory  I'esult  followecl.  If  tiiis  fracture 
had  been  examined  in  eight  days  after  its  receipt,  tiie  protrusion  of  the 
bone  would  have  been  detected  and  the  faulty  jjosition  rectified,  ^\'hile 
this  result  is  excejjtional,  such  unfortunate  complications  can  ahvays  be 
obviated  by  a  routine  inspection  of  the  fracture. 

There  are  some  questions  that  are  of  great  interest  when  discussed  in 
the  light  of  recent  revelations  in  surgical  jiathologv,  and  which  call  for 
special  study  and  observation  in  connection  with  the  treatment  of  com- 
jjound  fractures ;  such  aix"  malignant  disease,  tenotomy,  healing  by 
Schede's  method,  amputation,  the  conversion  of  simple  fractures  into 
compound,  and  compound  fractures  involving  the  major  joints. 

The  question  of  malignant  di  ease  following  fracture  is  an  exceedingly 
important  one  in  surgical  pathology.  The  late  Dr.  S.  D.  Gross  |)ointi'd 
out  the  important  fact  that  almost  half  of  the  cases  of  malignant  bone 
disease  can  be  traced  to  traumatism. 

The  author  recently  operated  upon  a  child  with  an  inmiense  sarcoma 
upon  the  occiput.  The  child  had  sustained  a  heavy  fall  upon  the  back 
of  the  head  six  months  previously,  followed  at  once  by  the  develojiment 
of  a  large  luematoma.     The  luematoma  was  not  incised,  and  a  linear 


526  FRACTURES. 

fracture  existed  beneath  it.  For  some  weeks  after  the  injury  ihcre  Mas 
nothiiifi'  sj^eeial  excepting  the  ])resenee  of  tlie  ineniatonia,  but  tlie  tumor 
then  l)eg'an  to  grow  very  rapidly,  and  in  less  than  six  nu^Tiths  from  the 
reeeij)t  of  the  injury  the  sarcoma  was  much  larger  than  the  child's  head. 
The  patient  died  some  weeks  after  an  incomplete  operation  for  removal 
of  the  tumor.  I  have  many  beautiful  specimens  illustrating  the  fact  that 
a  fracture  may  be  the  starting-])oint  of  this  variety  of  tumor. 

The  prognosis  of  sarcoma  affecting  bone  as  a  result  of  fracture,  while 
grave,  is  not  necessarily  fatal,  ])rovick'd  the  tumor  is  recognized  before 
glandular  swelling  appears  and  the  operation  is  performed  early  and 
includes  the  tissues  far  from  the  seat  of  disease  and  the  bone  itself. 

Ejiiihelioma  also  may  develop  indirectly  as  a  result  of  a  comj)ound 
fracture,  but  this  malignant  growth  has  its  origin  from  the  soft  tissues 
in  connection  with  a  sinus  leading  down  to  necrosed  bone.  If  a  sinus 
is  not  healed,  it  becomes  lined  with  epithelium,  and  a  discharge  of  ichor- 
ous pus  through  it  from  time  to  time  sets  up  an  irritation  with  a  pro- 
liferation of  epithelial  cells,  and  epithelioma  may  in  this  way  secondarily 
develop.  While  the  epithelioma  is  not  directly  connected  with  the  seat 
of  fracture,  as  is  the  case  in  sarcoma,  ncverthek'ss,  the  disease  inav  have 
its  origin  in  conditions  arising  from  secjucstration  in  a  com])ound  frac- 
ture. The  closure  of  sinuses  in  connection  with  necrosis  following  a 
fracture  should  always  be  aimed  at  by  the  surgeon. 

Six  years  ago  the  author  called  attention  to  tenotomy  in  the  treatment 
of  compound  fractures,  and  in  a  luinibcr  of  cases  since  then  he  has  been 
impressed  with  the  value  of  the  oj)eration  in  all  obli(|uc  i'om]iound  frac- 
tures, as  well  as  in  many  sim]>le  fractures.  Tenotomy  relieves  at  once 
any^  contraction  of  the  muscles,  permits  the  fragments  to  be  placed  in 
accurate  coaptation,  and  secures  physiological  rest  to  the  fracture.  It 
affords  also  great  comfort  to  the  patient,  and  is  a  valuable  means  of 
fixation  during  the  first  ten  days.  Tenotomy  may  be  employed  upon 
the  tendo  Achillis,  u])on  the  hamstring  nuisclcs,  u])on  the  tendons  of  the 
arm  and  forearm,  and  even  upon  the  sti'rno-eleido-mastoid  nuiscle  in 
fractures  of  the  clavicle.  In  several  cases  of  compound  fracture  of  the 
tibia  where  the  line  of  fracture  was  parallel  with  the  long  axis  of  the 
bone,  with  considerable  separation,  a  horseshoe  tourniquet  has  been  found 
to  be  a  most  valuable  instrument  in  closing  the  long  fissure.  The  instru- 
ment by  pressure  overcomes  the  lateral  separation,  just  as  tenotomy  by 
relaxation  overcomes  the  oblique  disjtlaccmcnt.  The  pad  can  be  ap]>lied 
upon  one  side  of  the  bone,  and  pressure  be  made  by  applying  the  other 
pad  over  a  thick  plaster  bandage.  The  screw  can  be  graduall}-  tight- 
ened, and  in  a  few  days  the  bone  can  be  ajiproximated  and  the  instru- 
ment discarded.  This  is  a  safer  and  more  satisfactory  instrument  than 
the  apparatus  devised  by  Malgaigne.  IMuscnlar  spasms  can  in  most 
eases  be  overcome  by  position.  Eelaxation  of  the  muscles  will  always 
relieve  the  spasm.  The  use  of  suljihonal,  as  well  as  of  many  other  drugs, 
has  been  suggested,  but,  as  a  rule,  they  do  not  relieve  the  condition. 

Healing  h\  Schede's  method  is  effected  by  the  intervention  of  blood- 
clots.  It  has  usually  been  taught  that  blood-clots  in  wounds  are  obsta- 
cles to  repair  by  primary  intention,  and  that  these  clots  act  as  foreign 
bodies. 

Fluid  blood  and  clots,  if  perfectly  aseptic,  are  valuable  adjuncts  in  the 


COMPOUND  FRACTURES.  527 

repair  of  oonijiound  fractures.  They  are,  however,  most  jiotent  sources 
of  evil  if  any  infectiou  reaches  the  ehit  tliroui;li  carelessness  of  the  sur- 
g'eoii.  It  is  a  most  vahiablc  contriinition  to  the  treatment  of  compound 
fractures  if  tiie  blood  whicli  escapes  between  the  ends  of  the  fraii'ments 
can  be  in  the  future  utilized  as  a  means  of  hastening  and  jierfccting 
union  by  primary  intention.  The  reason  why  so  important  a  principle 
in  snruieal  patholooy  has  l)cen  so  long  unknown  is  explained  by  the  fact 
tliat  blood-clots,  until  rigid  asepsis  was  established,  were  recognized 
st)urces  of  septic  infection.  If  all  the  surrounding  jinrts  in  every 
compound  fracture  are  made  asc|itie,  clots  and  fluid  blood  can  i>e  utilized 
for  the  purpose  of  healing.  Anything  short  of  absolute  surgical  clean- 
liness \vill  convert  these  clots  and  the  bhxid  into  dangerous  agents  of 
infection. 

Amjyiihttioii. — Anijnitation  of  the  liml)  in  comjxtuiid  fracture  was 
formerly  resorted  to  with  great  frequency  in  hospital  ])ractiee.  Before 
the  introduction  of  antiseptics  pyremia  destroyed  the  life  of  almost  every 
j)atient  suffering  from  compound  fracture  who  was  brought  to  a  large 
metropolitan  hospital.  The  time  is  within  my  own  recollection  when, 
in  Bellevue  Hospital,  amputation  was  immediately  performed  as  a  rou- 
tine treatment  to  prevent  blood-poisoning  iijion  tiie  admittance  of  a  com- 
pound fracture  ;  and  tliis  operation  was  considered  by  surgeons  as  offer- 
ing to  the  patient  the  i)nly  chance  of  recoxt'i-y.  At  the  present  time 
limbs  are  saved  which  Avould  then  have  been  sacrificed,  and  it  is  a  rare 
event  to  witness  an  amputation  in  compound  fracture.  Extensive  frac- 
ture of  the  bone  with  ])rotrusion  of  the  fragments  through  the  soft  struc- 
tures would  not  now  form  an  indication  for  amputation  unless  the  soft 
structures  were  badly  lacerated.  Formerly  the  loss  of  a  few  inches  of 
the  bone  called  for  primary  am])utation,  but  this  no  longer  offers  an 
indication,  for  the  bones  are  brought  together  by  silver  wire,  and,  though 
the  limb  may  be  shorter  than  its  fellow,  the  member  is  still  retained, 
and  elevation  of  the  shoe  compensates  for  any  slight  irregularity  in  the 
length  of  the  limb. 

The  limits  within  which  amputation  in  compound  fracture  may  be  re- 
sorted to  are  now  exceedingly  narrow  and  restricted,  and  this  clinical 
fact  is  one  of  the  most  notable  steps  in  the  advance  of  modern  surgery. 
Another  im])ortant  point  in  reference  to  amputation  in  compound  fracture 
is  the  proper  line  of  treatment  to  be  pursued  up  to  the  time  of  the  ope- 
ration. It  often  happens  that  a  patient  is  suffering  too  profoundly  from 
shock  to  make  it  expedient  to  amputate.  In  these  cases  great  benefit  is 
to  be  derived  from  deferring  the  amputation  even  many  days,  until  the 
condition  is  such  as  to  justify  the  operation.  Formerly  this  could  not 
be  practised  without  subjecting  the  patient  to  a  greater  risk  from  septic 
infection  than  wouldbe  incurred  by  an  amjiutation  during  shock.  If  the 
wound  is  at  once  made  aseptic  and  com]n-esses  are  jilaced  over  the  frac- 
ture to  control  the  hemorrhage,  and  these  compresses  do  not  extend 
higher  than  the  wound  itself,  the  amputation  can  be  deferred.  It  is 
important  that  these  compresses  be  apjilied  only  over  the  wound,  and 
that  no  tourniquet  or  any  other  form  of  compression  be  a]>]ilied  to  the 
limb  in  the  continuity  of  the  artery  above  the  injured  part  for  any 
length  of  time,  since  if  this  is  done  there  is  danger  of  gangrene  in  the 
fla]is  after  the  amputation.      In  one  ease  gangrene  followed  an  ani])uta- 


528  FRACTURES. 

tion  of  tlic  leg  where  a  tourniquet  liad  lieeii  ])lacecl  over  the  femoral 
artery.  This  j)atieiit  was  l)rou<;ht  to  tlie  hospital  from  a  ueighborino; 
town  with  a  tourniquet  upon  the  femoral  artery  for  the  ])urpose  of  arrest- 
ing hemorrhage  in  a  compound  fraeture  of  the  leg,  and  I  call  attention 
to  the  case  in  order  to  em])hasize  forciljly  this  point. 

The  conversion  of  simple  fractures  into  coni|)ound  or  complicated 
fractures  may  ha|)pen,  especially  when  the  muscular  spasm  is  great,  or 
(hiring  the  transportation  of  a  patient  suffering  from  a  sim])le  fracture.; 
or  there  may  be  spontaneous  conversion  by  means  of  the  necrosis  of  a 
small  fragment.  An  abscess  subsequently  forms  and  pus  is  set  free, 
and  the  seat  of  fracture  is  exposed  to  the  atmosphere.  The  author 
has  observed,  for  example,  a  Pott's  fracture — that  is  to  say,  a  frac- 
ture of  the  filmla  three  inches  above  the  tip  of  the  external  malleolus, 
with  a  laceration  of  tiie  deltoid  ligament — converted  after  several  weeks 
into  a  typical  compound  and  complicated  fracture,  owing  to  the  ne- 
crosis of  the  distal  fragment.  Suppurative  arthritis  of  the  ankle- 
joint  ensued,  with  caries  of  the  astragalus.  The  ankle-joint  was  opened, 
the  carious  fragments  removed,  the  joint  freely  irrigated,  and  an  anti- 
septic dressing  ap])lied.  The  patient  recovered  in  a  few  weeks  with  a 
useful  joint.  The  possibility  of  nature  transforming  a  simple  fracture 
into  a  complicated  one  must  not  be  overlooked.  In  such  cases  promj)t 
surgical  interference  may  arrest  the  progress  of  the  disease  and  effect 
perfect  restoration  of  a  joint ;  otherwise  this  complication  leads  to  irre- 
])arable  damage,  if  not  to  loss  of  life. 

The  treatment  of  compound  fractures  involving  major  joints  has  been 
entirclv  revoluti()nizcd  since  the  introduction  of  aseptic  surgery.  The 
unsatisfactory  results  in  fracture-dislocations  are  due  in  a  large  measure 
to  a  want  of  rigid  asepsis  on  the  one  hand,  and  a  too  extensive  operative 
interference  on  the  other.  For  examjile,  the  joint  may  not  be  rendered 
thoroughly  aseptic  at  the  beginning,  and  may  be  too  extensively  inter- 
fered with  as  regards  operative  procedures. 

In  the  171  compound  fractures  involving  joints  recorded  in  the 
1000  cases  referred  to  below  the  results  as  regai'ds  the  usefulness  of  the 
joint  have  been  in  nearly  all  the  cases  perfect.  To  have  a  compound 
fractiu-e-dislocati(jn  of  the  ankle-,  knee-,  elbow-,  or  shoulder-joint  re- 
paired with  complete  restoration  of  function  is  the  aim  of  the  surgeon. 
In  one  of  the  cases  the  asti'agalus  extruded  from  the  joint,  and  was  rein- 
serted, and  perfect  movement  of  the  joint  followed.  These  ideal  results 
are  to  be  obtained  only  by  the  exercise  of  great  care.  In  all  fracture- 
dislocations  the  joint  should  be  immediately  rendered  absolutely  aseptic 
by  thorough  irrigation.  The  drainage  should  be  entirely  across  the  joint, 
otherwise  a  ]50cket  for  the  retention  of  inflammatorv  exudates  is  sure  to 
form  in  the  fold  of  the  capsule.  These  products  luider  certain  conditions 
are  sources  of  great  danger.  A  careful  study  of  cases  of  fracture-dis- 
location reveals  the  history  of  an  abscess-formation  upon  the  side  of  the 
joint  opposite  to  the  original  wound  several  weeks  after  the  injury.  This 
complication  may  be  obviated  by  free  drainage.  It  is  not  sufficient  to 
drain  one  side  only,  and  that  side  through  the  original  opening  into  the 
joint,  but  the  tube  must  pass  entirely  through  and  across  the  joint. 
Physiological  rest  for  many  weeks  must  then  be  secured,  and  no  jiassive 
motion  employed  for  at  least  six  Meeks.     Passive  motion  too  early  em- 


COMPOUND  FRACTURES.  529 

ployed  has  often  excited  inflammation  which  has  led  to  suppurative 
arthritis.  Active  motion  must  follow  in  its  turn,  but  not  for  some 
time  after  the  employment  of  passive  motion  and  massage.  A  proper 
sequence  in  the  employment  of  these  different  agencies  is  most  iinjJort- 
ant  in  order  to  reach  an  ideal  result. 

The  complete  Iiistories  of  the  one  thousand  cases  of  compound  frac- 
tures have  been  carefully  recorded.    Tiie  general  summary  is  as  follows : 

Skull 178 

Nasal,  malar,  maxilla;,  and  patellae 89 

Arm 40 

Forearm 41 

Fingers  and  toes      97 

Ilium,  clavicle 2 

Thigh 87 

Leg ^ .    ._ 295 

Fractures  involving  shoulder-,  elbow-,  or  wrist-joints  as  a  result  of  disease 

or  accident 39 

Fractures  involving  hip-,  knee-,  or  ankle-joints  as  a  result  of  disease  or 

accident 85 

Fractures  involving  carpal  or  metacarpal,  tarsal  or  metatai-sal  joints  as  a 

result  of  disease  or  accident 47 

1000 

Xow,  following  the  example  of  surgical  writers  who  have  carefully 
tabulated  the  results  of  treatment  in  compound  fractures,  the  author  has 
eliminated  all  those  cases  in  which  primary  amputations  were  performed, 
because  they  do  not  concern  the  jioint  at  issue,  and,  according  to  the 
practice  of  writers,  has  rejected  all  those  cases  which  died  of  hemorrhage, 
collapse,  shock,  etc.  within  forty-eight  hours ;  in  fact,  most  of  such  cases 
died  within  a  few  hours  after  injury.  He  has  also  left  out  cases  of  com- 
pound fractures  of  the  hand  and  foot  as  too  insignificant  to  be  classed 
with  compound  fractures  of  the  long  bones  or  of  the  skull. 

In  the  total  of  1000  consecutive  (and,  of  course,  unselected)  cases  of 
compountl  fractiu'cs  produced  by  tramnatism  or  by  operation,  there  were 
101  deaths,  (JO  ])rimary  amputations,  and  4  cases  where  the  results  were 
unknown  on  accoiuit  of  the  removal  of  the  patients  from  the  hospital,  at 
their  own  request,  immediately  after  their  admittance.  In  the  101  deaths, 
82  died  within  forty-eight  hours  after  the  accident  and  during  shock,  and 
consequently  these  deaths  siiould  not  be  included  in  any  figures  to  a.scer- 
tain  the  percentage  of  mortality,  becau.se  the  patients  died  before  anv  plan 
of  treatment  could  be  adopted  having  reference  to  the  repair  of  the  frac- 
ture or  to  the  prevention  of  septic  infection. 

The  remaining  19  deaths  occurred  from  the  following  causes:  One 
from  tuberculous  meningitis  following  some  weeks  after  a  resection  of 
the  hip-joint,  so  that,  this  case  died  from  other  causes  than  septic  infec- 
tion ;  another  from  uriemia  in  ••hronic  Bright's  disease  one  week  after 
wiring  the  patella.  The  wound  was,  however,  healed  and  ])erfectlv 
aseptic,  so  that  this  case  died  from  other  causes  than  septic  infection. 
Another  died  one  month  after  tre]>hining,  from  exhaustion  and  inanition, 
with  the  wound  perfectly  healed  l)y  primary  intention,  and,  as  shown  by 
the  autopsy,  with  no  evidences  in  the  brain  of  the  pathological  changes 
of  sepsis,  so  that  death  in  this  case  cannot  be  attributed  to  septic  infec- 
tion.    Two  other  cases  died  from  irreparable  damage  to  the  brain,  in  one 

Vol.  I.— 34 


530  FRACTURES. 

of  which  the  lock  of  a  gun  was  driven  tlinnigii  tlie  skull  into  the  brain, 
and  in  the  other  a  fracture  at  the  base  was  found  at  the  autojjsy  in  addi- 
tion to  the  fracture  of  the  parietal  bone,  so  that  death  in  neitlier  of  those 
two  cases  was  due  to  pya?mia  or  septicemia.  Four  other  cases  died  from 
cerebral  softening,  which  was  situated  at  a  distance  from  the  original 
wound.  One  case  died  from  dipiitiieria  after  the  external  wound  of  the 
ciimpound  fracture  had  liealed.  Tlie  wound  was  asejitic,  and  was  never 
the  seat  of  any  disturbance,  and,  as  the  diphtheria  aft'ected  the  larynx  and 
trachea,  the  cause  of  death  was  in  no  way  connected  with  the  fracture, 
altliough,  of  course,  the  time  was  too  short  to  have  the  bone  firmly  united. 
One  case  of  compound  fracture  of  the  skull  died  on  the  fifth  day,  but  in 
this  case  the  ])atient  was  suffering  from  a  fracture  of  the  spine  which 
caused  his  death  by  myelitis.  One  case  died  within  forty-eigiit  liours 
after  admittance  from  cerebral  abscess  connected  with  a  punctui-ed  fracture 
of  the  skull,  which  had  been  operated  upon  two  Mceks  previously  by  a 
surgeon  in  a  neighboring  town.  During  tlie  jiatient's  sojourn  in  the 
hospital  he  was  trephined  and  seven  ounces  of  pus  were  evacuated  from 
the  brain,  but  he  died  a  few  hours  later.  This  case  is  excluded,  on  the 
gnnuid  that  the  patient's  injury  was  not  treated  in  the  hospital,  and 
that  he  did  not  enter  the  hospital  until  within  forty-eight  liours  of 
liis  death.  The  death  was  clearly  due  to  sepsis,  but  the  circumstances 
were  such  as  to  relieve  the  hospital  surgeon  from  all  responsil^ility. 
One  case  died  after  forty-eight  hours,  but  it  was  a  case  of  primary  ampu- 
tation. The  patient  was  run  over  by  a  locomotive ;  both  feet  were 
crushed,  and  the  hanging  toes  were  removed  as  soon  as  his  condition 
would  permit.  One  case  similar  to  the  last  died  fi-om  a  crushed  foot 
ninety  hours  after  the  accident.  The  jiatient  was  over  sixty  years  of  age, 
and  never  reacted  from  the  shock.  The  remaining  case  of  death  was  due 
to  lej)tomeningitis,  which  occurred  fifty-two  hours  after  trephining,  and 
was  due  to  sejisis. 

Finallv,  in  order  to  arrive  at  the  mortality  in  this  list  of  one  thousand 
compound  fractures,  there  must  be  deducted  from  the  original  1000  eases 
60  primary  amputations,  because  no  treatment  of  the  fracture  itself  was 
undertaken ;  82  deaths  from  shock  occurring  within  forty-eight  hours, 
because  no  treatment  was  begun  ;  4  cases  where  the  result  is  unknown, 
because  the  patients  left  the  hospital  of  their  own  accord;  155  cases 
of  compound  fractures  of  the  fingers  and  toes,  because  tiiey  are  too 
insignificant ;  also  1 8  cases  just  mentioned  in  detail.  There  then  remain 
681  cases  of  compound  fractures  witli  one  death  due  to  sepals.  This 
gives  a  death-rate  of  about  one-seventh  of  1  per  cent.  The  reduction  of 
the  death-rate  from  48  per  cent.,  which  half  a  century  ago  was  considered 
a  brilliant  achievement  and  a  result  which  was  thought  worthy  of  jniblica- 
tion,  to  that  of  one-seventh  of  1  ycr  cent,  represents  what  surgery  has  done 
for  the  amelioration  of  human  sufi'ering  and  the  preservation  of  life  in 
this  special  field  of  sui-gery.  To  Pasteur  and  to  Lister  the  profession  are 
indebted  for  this  great  work — the  former  as  the  discoverer  of  the  means, 
and  the  latter  as  the  one  who  ap|)lied  the  discovery  to  surgery. 

Complications. — Compliccdions  during  and  after  repair  of  fractures 
forms  a  most  interesting  subject  for  observation  and  study.  The  com- 
plete usefulness  of  a  limb  is  not  fully  restored  as  soon  as  the  fracture 
has  been  repaired.     During  the  process  of  repair,  as  well  as  after  union 


COMPLICATIONS.  531 

is  complete,  it  is  jjossible  for  many  comjilications  to  arise  that  rccjuire 
special  treatineut. 

Surgical  emphysema  is  a  condition  that  is  often  met  with  in  the  man- 
agement of  fractnres.  This  consists  of  the  entrance  of  atmosplicrie  air 
into  the  meslies  of  the  connective  tissne,  and  is  termed  "surgical  emphy- 
sema "  to  distinguish  it  from  emphysema  of  the  lung.  The  source  of 
tiic  intiltratiiin  of  the  air  into  tlie  connective  tissue  may  be  from  injury 
of  the  lung  in  fracture  of  the  rib,  in  wiiich  case  the  emphysema  has  been 
observed  to  reach  to  the  scrotum,  and  at  times  it  may  spread  over  the 
face,  so  that  the  jiatient  is  unrecognizable.  The  air  may  escape  to  such  an 
extent  as  seriously  to  embarrass  respiration.  Another  source  of  emphy- 
sema may  be  from  the  generation  of  gases  as  a  result  of  putrefactive 
changes  or  of  the  growtii  of  gas-producing  bacilli  in  the  tissues.  There 
are  only  a  few  cases  oljserved  of  emphysema  in  simple  fractures ;  the 
majority  of  the  cases  have  been  comjilications  in  compound  fractures. 
Or  the  gas  may  escape  from  a  wound  in  tlic  intestine,  or  even  from  the 
air-sinuses  in  the  bones  of  the  face  and  skull. 

If  the  emphysema  arises  from  injury  to  the  lung,  no  interference  is 
indicated  unless  the  emphysema  is  so  extensive  as  to  produce  dyspnoja, 
in  which  case  free  incisions  can  be  made  or  the  air  allowed  to  escape 
through  a  trocar.  The  air  is  usuall}^  absorbed  in  a  few  weeks,  and 
produces  no  harm,  since  it  has  been  filtered  in  its  jiassage  through 
the  lungs,  and  is  therefore  incapable  of  setting  up  inflammation.  In 
case  tile  condition  arises  from  putrefactive  changes,  the  apjilication  of 
the  ]>rinciples  of  antiseptic  surgery  is  required  ;  if  from  a  wounded 
intestine,  a  laparotomy  must  be  performed  at  once,  the  peritoneal  cavity 
rendered  aseptic,  and  the  wound  closed. 

Q^demn  consists  of  the  infiltration  of  serous  fluid  into  the  interstices 
of  the  areolar  tissue,  and,  unless  it  is  due  to  some  organic  disease  of  the 
liver,  kidney,  or  heart,  is  the  result  of  too  tight  bandaging  or  the  sudden 
removal  of  tiie  splint,  or,  finally,  of  obliteration  of  the  large  veins 
frijui  thrombosis.  If  due  to  local  causes,  the  oedema  usually  disappears 
after  the  removal  of  the  cause,  or,  if  to  a  loss  of  support  of  the  vessels 
by  the  removal  of  the  splint,  the  oedema  rapidly  subsides  as  soon  as  the 
function  of  the  limb  is  restored.  Placing  the  limb  under  a  faucet  and 
doucliing  it  alternately  with  hot  and  cold  water  will  stimulate  the  circu- 
lation ;  and  this  treatment,  aided  by  the  action  of  the  muscles  when  the 
patient  begins  to  walk,  will  relieve  the  condition. 

Delirium  tremens  and  traumatic  delirium  are  two  complications  that 
frequently  occur.  The  differential  diagnosis  is  often  difficult  to  make, 
but  tremor  in  the  limbs  and  an  alcoholic  history,  with  absence  of  fever, 
point  to  the  former  as  contrasted  with  the  latter  condition.  In  both 
forms  of  delirium  the  ]iatient  has  delusions,  mutters  incoherently,  is 
often  violent  and  excitable,  and  has  a  dry,  tremulous  tongue  accompanied 
by  free  diaphoresis. 

The  treatment  consists  in  placing  the  fracture  at  once  in  a  plaster-of- 
Paris  splint  and  watching  the  jiatient  carefully,  even  to  the  extent  of 
employing  a  special  attendant.  If  the  delirium  becomes  too  active,  and 
it  is  impossible  to  restrain  the  jiatient,  a  strait-jacket  must  be  cmplo}'e<l. 
If  the  patient  is  robust  and  young,  alcohol  can  Ije  witiiheld,  but  if  aged 
and  feeble,  it  is  necessar}'  to  continue  stimulants  with  judgment. 


532  FRACTURES. 

The  bromides,  chloral,  hyoscyamus,  and  in  some  cases  morphine,  are 
the  remedies  which  have  proved  the  most  successful.  In  organic  disease 
of  the  kidney  morphine  is  apt  to  cause  suppression  of  urine,  and  must 
be  enijtloyed  with  caution.  The  diet  must  be  nutritions  and  abundant, 
and  the  patient's  strength  maintained. 

Fncumonia  is  a  complication  likely  to  arise  during  the  repair  of  a 
fracture.  It  is  especially  likely  to  occur  in  alcoholic  patients  and  in 
compound  fractures,  and  forms  a  most  serious  complication.  The  treat- 
ment of  the  disease  is  conducted  upon  the  same  principles  that  govern 
the  physician  in  a  case  of  ordinary  pneumonia. 

Tetanus  is  fortiniately  a  rai-e  complication  occurring  during  the  repair 
of  fracture.  In  a  tabulation  of  over  twelve  thousand  fractures  there  were 
25  deaths  from  tetanus,  or  about  1  case  in  5U0  fractures.  In  the  25  cases 
of  tetanus  taken  from  this  large  list  the  disease  develojjed  in  only  3 
simple  fractures.  The  propoi'tion  of  cases  of  tetanus  in  all  kinds  of 
fractures  is  only  about  1  per  cent.  The  greater  nundjer  of  cases  of  tetanus 
occurring  in  compound  fractures  is  explained  by  the  entrance  of  the 
bacilli  of  tetanus  from  external  sources  of  infection,  as  dirt,  air,  and 
surrounding  media.  This  percentage  was  derived  from  cases  treated  in 
pre-antiseptic  days,  so  that  with  antiseptic  princijiles  applied  to  the 
dressing  of  a  compound  fracture  tetanus  ought  not  to  apjiear  as  a  com- 
plication. In  tlie  author's  list  of  one  thousand  cases  of  compound  frac- 
tures no  case  of  tetanus  appeared.  The  tlisease  usually  occurs  in  com- 
pound fractures,  and  esjjccially  those  of  the  fingers  and  toes,  in  which 
over  50  per  cent,  of  the  cases  of  tetanus  occurred.  Compound  fractures 
of  the  thigh  furnished  a  large  percentage  of  the  cases.  The  cause  of  the 
disease  is  tlie  presence  of  the  bacillus  of  tetanus.  The  treatment  con- 
sists of  division  of  the  main  nerve-trunk  or  stretching  it,  or  even  ampu- 
tation of  the  extremity.  Calal)ar  bean,  morphine,  chloral,  the  bromides, 
the  inhalation  of  chloroform,  and  the  Russian  bath  have  been  emjjloyed 
with  varying  degrees  of  success.  For  a  full  description  of  the  treatment 
the  reader  is  referred  to  the  article  on  Tetanus.  Strict  antisepsis  must 
be  rigidly  enforced  in  any  case,  since  the  disease  is  due  to  the  presence 
of  a  specific  germ. 

OdeornycUfis  is  a  form  of  supjnu'ation  in  bone,  and  is  caused  by 
the  presence  of  septic  micrococci  in  the  wound.  It  is  therefore  most 
likely  to  occur  in  compound  fractures,  although  the  disease  in  the  form 
of  acute  abscess  may  occur  after  any  traumatism  of  bone.  The  osteo- 
myelitis sets  up  necrosis  of  bone,  and  the  patient  may  die  from  septic 
infection  before  the  sequestrum  can  be  removed.  Septic  emboli  may 
start  from  the  thrombi,  and  metastatic  abscesses  develop.  The  treatment 
of  this  condition  consists  in  freely  exposing  the  seat  of  the  abscess,  and 
tre]>hining  the  bone  above  it  if  necessary  in  order  to  reach  the  disease, 
with  a  view  to  destroying  the  micro-organisms  with  a  solution  of  bichlor- 
ide of  mercury.  The  application  of  the  ]n-inci])lcs  of  antiseptic  surgery 
will  destroy  the  disease,  and  if  not  amputation  of  the  limb  is  indicated. 

Fdf-cmbolism  was  first  fully  described  by  A\'agner  and  Zenker. 
Fat-embolism  means  the  entrance  of  fluid  flit  from  the  medulla  of  the 
bone  into  the  veins  in  the  immediate  vicinity  of  the  fracture,  and 
through  these  channels  into  the  capillaries  of  the  brain,  spinal  cord, 
lungs,  kidneys,  and  other  essential  organs.     The  presence  of  fluid  fit  in 


COMPLICATIONS.  533 

the  blood  was  descril)ed  in  1836  by  Dr.  R.  W.  Smitli,  but  the  clinical 
importance  of  this  condition  was  not  I'ecognized  until  recently  through 
the  investigations  i)f  Bergniann,  Czerny,  and  Scriba.  Dejerine  has  ex- 
perimentally produced  fat-embolism  in  the  lower  animals  by  inserting 
laminaria  tents  into  the  medullary  cavity  of  the  l)one.  The  symjitoms 
of  fat-embolism  appear  on  from  tiie  third  to  the  fifth  day  as  a  rule,  and 
resemble  those  of  secondary  shock.  They  occur  before  the  time  at  which 
venous  thrombosis  or  pulmonary  embolism  would  be  expected  to  appear. 
Great  dyspntea,  associated  \vith  tlie  Cheyne-Stokes  respiration,  irregularity 
of  the  heart's  action,  with  a  sudden  rise  of  temperature,  together  with 
twitching  of  the  nuiscles,  as  well  as  paralysis  of  certain  muscles,  have 
been  observed  in  these  cases,  and  also  fat-globules  are  found  in  the 
urine.  There  have  been  no  metastatic  abscesses  discovered  where  an 
autopsy  has  been  made.  This  group  of  symptoms  must  not  be  mis- 
taken for  shock  following  fracture  nor  for  jiulmonarv  enil)olism. 
Shock  may  be  said  to  be  present  three  hours:  after  the  fracture,  fat^ 
embolism  ihrer  dai/s  after,  and  jiuliiKinary  embolism  three  veeks  after. 
For  convenience  these  complications  have  been  arranged  in  the  order 
in  which  they  are  most  likely  to  occur,  and  by  associating  these  condi- 
tions, which  simulate  each  other,  with  the  time  at  Avhich  they  appear, 
no  mistake  in  diagnosis  is  likely  to  arise. 

The  treatment  of  fat-embolism  consists  in  the  administration  of  etiier 
in  the  form  of  some  such  preparation  as  Hoffman's  anodyne,  or  even  l)y 
hyjiodermic  injection.  In  ease  of  great  dyspnoea  venesection  has  been 
suggested,  and  also  artificial  respiration.  The  pulmonary  oedema  must 
be  relieved  by  cardiac  stimulants  and  by  cupping.  The  fracture  should 
be  kept  perfectly  quiet,  lest  any  movement  of  the  fragments  might  cause 
furtlier  absorption  of  the  fat  by  disintegrating  the  medulla.  In  cases 
wliere  there  is  great  cimiminution  of  bone  and  disintegration  of  the 
medulla  amputation  may  be  immediately  indicated  as  a  life-saving 
expedient. 

<Tanf/rene  of  the  limb  may  occur  either  as  a  result  of  mechanical  or 
traumatic  causes  or  from  septic  infection.  Gangrene  arising  from  mechan- 
ical causes  is  due  to  the  application  of  too  tight  a  splint  or  bandage  or 
to  the  improper  and  prolonged  use  of  a  tourniquet.  The  gangrene 
resulting  from  traumatic  causes  is  due  to  a  crushing  or  laceration  of  the 
soft  structures  near  the  fracture,  or  else  to  the  rupture  of  the  main  ves- 
sels by  the  same  agency  which  produced  the  fracture,  or  by  the  sharp 
fragments  of  bone,  or,  finally,  to  pressure  from  hemorrhage  or  from  an 
unreduced  fragment.  The  occurrence  of  gangrene  often  leads  to  suits 
for  malpractice  in  the  treatment  of  fractures.  It  is  therefore  important 
for  the  surgeon  to  define  clearly  the  causes  over  which  he  has  control, 
and  those  which  are  beyond  his  control,  such  as  contusion,  laceration  of 
blood-vessels  or  nerves,  pressure  of  a  fragment  of  bone,  or  the  oblitera- 
tion of  the  lumen  of  the  artery  from  thrombosis  due  to  senile  changes  or 
calcification  of  the  artery,  and  the  jiresence  of  diabetes,  with  Mliich  gan- 
grene is  so  often  associated,  especially  after  an  injury. 

The  treatment  nuist  depend  upon  the  cause,  the  extent,  and  the  gen- 
eral infection  of  the  patient.  In  small,  localized  areas  of  gangrene 
measures  should  be  adopted  to  encourage  the  separation  of  the  slough, 
while  in  gangrene  with  a  line  of  demarcation  forming  amputation  can 


53-1  FRACTURES. 

be  resorted  to  when  the  heahhy  and  dead  tissues  are  clearly  defined.  In 
case  of  rapidly-spreading  gangrene,  with  symptoms  of  serious  septic 
intoxication,  amputation  high  above  the  gangrene  shuukl  be  immediately 
performed. 

Fi/cvmia  and  .scptic.cemia  are  conditions  which  arise  in  the  course  of 
the  repair  of  a  fracture,  and  for  a  full  description  of  these  complications 
the  reader  is  referred  to  the  article  devoted  to  a  consideration  of  this 
subject. 

Thrombosis  is  a  complication  that  under  rare  circumstances  occurs. 
When  a  vein  has  been  wounded,  a  clot  forms  which  closes  the  vessel. 
From  this  thrombosis  an  embolus  has  been  known  to  originate  and 
travel  to  the  lung,  where  it  has  caused  death  by  plugging  up  the  pul- 
monary artery.  This  complication  occurs,  without  any  warning,  about 
three  ^^■eeks  after  the  receipt  of  tlie  fracture.  The  patient  exjiires  sud- 
denly witli  great  dys])n(ea,  cyanosis,  feelile  pulse,  and  angina  pains. 
It  occasionally  happens  that  small  emboli  may  become  detached,  and 
produce  alarming  symptoms  which  gradually  disappear.  In  all  cases 
where  there  has  been  obliteration  of  the  veins,  with  formation  of 
thrombi,  it  is  dangerous  to  jiractise  massage  early  or  to  disturb  the  seat 
of  fracture,  since  an  embolus  might  be  torn  a^\■ay  from  the  thrombus 
and  set  free  in  the  circulation. 

Hemorrhage  to  a  certain  extent  occurs  after  every  fracture,  but  the 
amount  is  usually  so  small  that  it  requires  no  treatment.  If,  however, 
the  quantity  is  large,  there  is  danger  of  sloughing  and  gangrene,  owing 
to  pressure.  The  seat  of  the  hemorrhage  is  between  the  integument 
and  fascia,  or  it  may  be  beneath  the  fascia.  The  source  of  the  hemor- 
rhatre  mav  be  from  the  medulla  of  the  bcme,  from  the  associated  contu- 
sion  and  laceration  of  the  soft  structures,  or  even  from  a  rupture  of 
the  main  artery  or  vein  of  the  limb.  When  the  hemorrhage  is  from 
the  medulla  the  blood  escapes  from  the  broken  ends  of  the  fragments, 
and  after  a  few  days  undergoes  absorption.  When  the  hemorriiage  is 
from  the  contusion  of  the  soft  parts  the  amount  may  he  considerable. 
The  blood  may  apjiear  in  the  form  of  a  fluid  tumor  t)r  as  a  semi-solid 
mass  due  to  coagulation.  If  the  l)lood  is  fluid,  an  aspirating  needle, 
rendered  aseptic,  can  be  introduced  into  the  tumor  and  the  blood  with- 
drawn, and  at  the  same  time  equable  compression  can  be  employed  in 
order  to  obliterate  the  space  or  cavity  which  is  formed  by  the  sudden 
withdrawal  of  the  blood.  If  the  blood  has  coagidated,  the  clot  may 
undergo  a  certain  amount  of  absorption  and  contraction,  or  it  may  by 
pressure  cause  irritation,  and  by  tension  set  up  inflammatory  reaction, 
quickly  followed  by  suppuration.  If  the  latter  takes  place,  the  abscess 
must  lie  opened,  the  remnants  of  the  clot  removed,  the  cavity  irrigated 
with  a  bichloride  solution,  and  then  dressed  antiseptically.  If  the 
hemorrhage  proceeds  from  a  rupture  of  the  main  artery  of  the 
limb,  a  traumatic  aneurism  is  formed.  If  the  aneurism  is  small,  the 
pulsation  is  feeble,  and  the  circulation  is  good  in  the  distal  branches  of 
the  artery,  slight  digital  pressure  on  the  main  artery  above  the  aneurism 
Avill  sometimes  cure  the  aneurism.  If  an  artery  is  wounded  subcu- 
taneously  as  a  result  of  fracture,  and  the  hemorrhage  is  not  excessive, 
it  often  happens  that  in  a  healthy  patient  repair  will  take  place  without 
any  operation.     If,  however,  the  aneurism  is  large,  the  pulsation  strong, 


COMPLICATIONS.  535 

the  circulation  below  the  injured  vessel  feeble  or  entirely  shut  off,  and 
the  patient  in  a  dangerous  condition  from  loss  of  blood,  the  operation 
of  cutting  down  upon  the  vessel,  turning  out  the  clot,  and  ligaturing 
both  cndx  should  be  immediately  performed.  If  the  femoral  artery  is 
wounded,  or  both  til)ials,  this  operation  of  ligating  may  be  inadequate, 
and  the  condition  may  call  for  amputation.  In  primary  hemorrhages 
both  ends  of  the  divided  vessel  should  be  sought  for  and  ligated  in  the 
wound,  while  in  secondary  hemorrhage  the  vessel  sh(juld  be  tied  in  its 
continuity,  and  above  in  healthy  tissue. 

Atrophji  of  the  limb  following  fracture  is  a  complication  that  is  likely 
to  occur,  especially  when  there  has  been  long-continued  disuse  of  the  limb, 
as  in  fracture  of  the  patella.  The  atrophy  is  most  marked  in  the  muscles 
above  rather  than  in  those  below  the  joint  nearest  to  the  fracture,  and  it 
is  especially  prone  to  appear  in  rheumatic  diatheses  and  to  involve  the 
extensor  muscles.  Tlic  atrophy  involves  the  connective  tissue  as  well  as 
the  muscles,  and  the  condition  may  be  dependent  upon  an  injury  to  the 
nerves  in  the  limb,  or  possibly  to  a  too-prolonged  use  of  contimious 
compression.  The  atrophy,is  susceptible  to  treatment  by  gentle  massage, 
hypodermic  injection  of  strychnia,  shampooing  of  the  limb,  and  mod- 
erate exercise. 

Parali/fiis  of  the  viu.'<o/cs  below  the  seat  of  fracture  may  occur  as  a 
complication  during  the  repair  of  fracture,  as  a  result  either  of  associated 
injury  to  the  nerves  supplying  the  affected  muscles  or  of  an  inclusion  of 
the  nerves  in  an  exuberant  callus  during  the  process  of  repair.  In  the 
former  case  the  paralysis  is  present  simidtaneously  with  the  occurrence 
of  the  fracture,  and  if  the  nerve  is  a  mixed  one  there  will  be  loss  of 
motion  and  sensation.  The  simple  tests  for  motion  and  sensation 
should  be  made  in  examining  every  case  of  fracture,  since  a  paralysis 
which  is  overlooked  at  the  time  of  the  examination  of  the  fracture 
may  be  attributed  subsequently  to  carelessness  on  the  part  of  the 
surgeon.  This  knowledge  will  prevent  any  j)0ssible  claim  for  dam- 
ages. In  the  latter  case,  where  the  paralysis  results  from  pressure  of 
callus,  the  symptoms  appear  gradually  and  some  time  after  the  occur- 
rence of  the  ft'acture. 

In  cases  where  the  paralysis  is  due  to  pressure,  electrical  stimulation 
of  the  main  nerve-trunk  above  the  callus  fails  to  excite  the  muscles  to 
wliich  tiie  nerve  is  supplied. 

The  treatment  consists  in  extricating,  if  ])ossible,  the  nerve  from  the 
callus  by  means  of  a  surgical  operation,  and  the  application  of  the  con- 
stant current  to  the  nerve  until  it  has  regained  its  function. 

Anki/losis  of  jotntx  occurs  as  a  complication  following  fracture.  The 
ankylosis  may  be  either  jiermanent  or  temporary.  The  permanent 
variety  consists  of  all  osseous  ankylosis,  and  the  condition  is  a  result  of 
a  fracture  directly  into  the  joint,  so  that  the  fragments  within  the  j(jint 
have  become  united.  For  the  removal  of  this  condition  surgery  can 
offer  no  relief  unless  an  asejitic  resection  of  the  joint  is  performed,  and 
this  operation  is  limited  to  a  few  of  the  joints,  like  the  shoulder,  elbow, 
wrist,  and  ankle,  with  possibly  a  few  others.  The  tem]iorary  ankylosis 
is  the  result  of  a  concomitant  injur}-  which  has  set  uj)  an  arthritis,  or 
it  may  be  due  to  the  prolonged  use  of  extension  in  the  treatment  of 
certain  fractures,  or  it  may  be  the  result  of  hemorrhage  into  the  joint 


C36  FRACTURES. 

which  lias  excited  a  synovitis  and  artliritis,  witli  tlie  formation  of  intra- 
articular Ijands  of  fibrous  tissue.  In  Colles's  fracture  the  fing'ers  ai'e  often 
stiff  from  a  thecal  inflammation,  and  it  is  with  great  difficulty  that  this 
condition  can  be  relieved. 

The  treatment  consists  in  massage,  shamjiooincj-,  the  use  of  hot  fo- 
mentations of  bran,  the  alternate  douching  with  hot  and  cold  water,  and 
active  movement. 

Necroi^i.s  of  hone  occurs  as  a  complication  during  the  repair  of  frac- 
ture, and  is  due  to  the  fact  that  the  jieriosteum  has  been  detached  from 
the  fragment  or  else  from  the  shaft  of  the  bone.  In  the  former  case  the 
loose  fragment  should  be  removed  at  the  time  of  the  reduction  and  first 
dressing ;  in  the  latter  case  the  superficial  scale  of  bone  undergoes  ne- 
crosis, owing  to  its  diminished  vascular  sujiply.  Generally  a  sinus  leads 
down  to  the  exfoliated  bone.  This  tract  should  be  excised  and  the  bone 
removed,  as  a  long-continued  sinus  discharging  ichorous  pus  is  a  condi- 
tion favorable  to  the  development  of  an  ejiithelioma. 

Non-union  of  bone  occasionally  occurs.  In  many  cases  the  frag- 
ments may  fail  to  unite  at  the  usual  time,  and  even  fail  after  several 
attempts  to  induce  repair;  but  eventually  union  can  be  accom]>lished. 
The  author  some  yt'ars  ago  published  a  report  of  one  thousand  com- 
pound fractures,  and  in  this  list  there  was  no  case  in  which  finally 
union  was  not  obtained.  Assuming  that  one  eomjiound  fracture  occurs 
to  every  ten  simple  fractures,  there  woidd  be  nearly  ten  thousand  cases 
of  fractured  bones  in  which  the  author  cannot  recall  a  single  case  of  per- 
manent non-union.  AMiere  the  fragments  could  be  approximated  they  in 
a  few  cases  failed  to  unite  after  several  attemjrts  in  the  way  of  o])erative  in- 
terference, but  finally  a  union  was  effected,  although  in  several  cases  as  many 
as  seven  or  eight  operations  were  performed.  The  femur  and  the  hiimerus 
occasionally  fail  to  unite,  and,  next  to  these,  the  bones  of  the  leg,  and 
lastly  the  bones  of  the  forearm.  That  part  of  the  bone  which  is  away 
from  the  direction  of  the  nutrient  artery  is  most  likely  to  give  rise  to 
non-union.  In  the  sitting  posture,  if  the  elbow-  and  knee-joints  are 
strongly  flexed,  the  nutrient  arteries  take  a  direction  downward,  or  in  the 
upper  extremity  the  nutrient  arteries  run  loirard  the  central  joint,  wliile 
in  the  lower  extremities  the  nutrient  artries  run  cncaji  from  the  central 
joint.  From  this  anatomical  law  the  upper  part  of  the  humerus  would 
be  the  most  frequent  seat  of  ununited  fracture  ;  and  in  siqiport  of  this 
statement  out  of  13  cases  reported  of  ununited  fractures  of  the  humerus, 
9  were  in  the  upper  extremity  of  the  bone.  In  8  ununited  fractures  of 
the  forearm,  7  were  in  the  lower  part.  In  the  same  manner,  ajiplying  this 
anatomical  law  to  the  lower  extremity,  it  is  found  that  the  cases  of  non- 
union are  found  in  a  very  large  proportion  of  the  cases  in  the  lower  jiart 
of  the  femur  and  in  the  upper  part  of  the  tibia.  The  intra-capsular  frac- 
ture of  the  neck  of  the  thigh-bone  is  an  exception,  but  in  this  case  the 
non-union  is  due  to  special  causes,  which  will  be  considered  in  a  dis- 
cussion of  this  special  fracture. 

The  (xtuscs  of  non-union  in  bones  after  fracture  are  constitutional  and 
local.  Among  the  constitutioval  causes,  in  which  the  reparative  action 
is  impaired  or  misdirected,  may  be  mentioned  old  age  and  certain  con- 
stitutional diseases,  as  fevers,  syphilis,  scurvy,  malignant  disease  of  bone, 
and  rickets.      Paralysis  may  also  be  a  cause,  as  is  illustrated  by  a  case 


NON-UNION  OF  BONE.  537 

of  spinal  injury  with  fracture  of  the  linnierus  and  leii  of  the  same  side, 
in  whieli  the  arm  united,  hut  the  k'g  failed  to  unite. 

The  puerperal  state  is  another  eonstitutional  cause  whicii  has  been 
mentioned  hv  some  writers,  but  the  author  has  never  found  this  condition 
to  permanently  cause  a  non-union  in  fractured  bones,  although  in  some 
cases  the  bones  fail  to  unite  until  after  parturition  or  until  several  opera- 
tions have  been  performed. 

Among  the  local  causes  of  non-union  may  be  mentioned  the  direc- 
tion of  the  line  of  fracture,  since  oblique  fractures  are  more  frecpiently 
attended  Ijy  failure  of  tuiion  tJian  transverse  or  impacted.  Among  the 
other  causes  may  be  found  sei)a)-auon  of  the  fragments,  the  interpositiou 

Fig.  44. 


of  foreign  botlies  between  the  ends  of  the  broken  bones,  or  suppuration, 
profuse  hemorrhage,  the  continued  use  of  wet  dressings,  and,  finally, 
improper  dressings,  in  which  the  splints  are  either  too  tight  or  too  loose 

The  treatment  ot  non-iuiion  of  bone  following  fracture  is  to  be  con- 
sidered from  a  constitutional  as  well  as  a  kical  jioint  of  view.  It  is 
the  union  of  the  two  methods  that  is  sure  speedily  to  bring  about  the 
desired  object.  In  every  case  a  careful  incpiiry  should  be  made  in  regard 
to  certain  diatheses.  The  treatment  of  this  unfortunate  condition  has  for 
its  oliject  the  correction  of  any  constitutional  dyscrasia.  A  syphilitic 
diathesis  should  be  treated  with  the  full  administration  of  antisyphilitic 
remedies ;  a  gouty  or  rheumatic  tendency,  by  remedies  suited  to  these 
special  diseases ;  scurvy,  rickets,  scrofula,  tuberculosis,  and  marasmus 
should  be  treated  with  tonics  and  a  nutritious  diet,  with  the  aid  of  the 
best  hygienic  surroundings.  The  tonics  best  suited  for  those  condition.' 
in  which  the  general  health  is  impaired  are  iron  and  the  phosi)hates. 

In  conjunction  with  the  general  management  the  local  treatment  is  to 
be  pursued.  The  means  emjiloycd  must  consist  of  the  removal  of  any 
offending  body  between  the  fragments  and  the  excitation  of  a  certain 
amount  of  inflammation  aroiuid  the  ends  of  the  fragments.  The  local 
treatment  must  further  consist  in  the  application  of  an  immovable  splint 
specially  ada])ted  to  the  exigencies  of  the  case. 

The  operations  which  have  been  devised  with  a  view  to  effecting  union 
in  ununited  fra<"ture  are  nniltifarious.  They  all  have  one  common  olijcet — 
viz.  the  excitation  of  inflanimation  ;  but  many  of  the  old  operations  are 
at  the  present  time  abandoned  as  a  result  of  the  introduction  of  anti- 
septic surgery.  The  use  of  the  seton,  the  injection  of  irritating  fluids, 
the  cauterization  of  the  fragments,  the  application  of  blisters  and  of 
caustic  alkalies  to  the  skin  over  the  site  of  the  ununited  fracture,  the 


s 


538 


FRACTURES. 


Fig.  45. 


introduction  of  electrical  cnrrents,  the  violent  jiercus.sion  witii  the  mallet, 
— are  among  the  varions  operations  which  are  practically  discarded  as 
luisnitalile,  and  in  their  place.s  modern  surgery  has  instituted  a  number 
of  asej)tic  operations. 

Before  any  other  operation  is  attempted  it  is  good  surgery  to  try  and 
perforate  the  bones,  which  is  best  accomplished  by  a  Bi-ainard  drill. 
This  operation  is  simi)le,  is  attended  with  no  special  danger,  and  in  the 
majority  of  cases  will  bring  al)out  firm  union.  This  method  is  espe- 
cially indicated  in  cases  where  the  patient's  healtli  is  impaired,  or  the 
patient  is  aged,  or  where  any  lesion  of  important  organs  exists,  such 
as  would  render  a  more  serious  operation  a  source  of  great  danger.  This 
operation  can  be  accomplished  without  the  administration  of  ether,  and 
with  but  little  pain,  by  the  use  of  the  freezing  atomizer  and  by  the 
hyjHidermic  injection  of  cocaine  through  the  ana\sthctized  skin  :  a  small 
incision  is  made,  and  the  drill  is  thrust  into  the  Ijone.  The  drill  pene- 
trates the  fragments  in  twenty  or  thirty  places  from  the  same  opening  in 
the  skin.  In  these  cases  the  ends  of  the  fragments  are  usually  devoid 
of  periosteum,  and  the  intervening  tissue  forming  a  false  joint  is  jiartially 
insensitive  ;  hence  the  pain  is  not  unbearable.  The  soft  parts  around  the 
seat  of  fracture  shoidd  be  thoroughly  cleansed  before  drilling  the  bones, 
and  the  small  puncture  in  the  skin  made  aseptic  before  being  hermet- 
ically closed.  Closure  of  the  wound  is  best  eft'ected  by  iodoform  powder 
freely  sprinkled  over  the  wound,  and  over  the  powder  should  be  painted 

styptic  collodion  with  a  thin  film  of 
borated  cotton,  and  in  this  way  a  firm 
scab  is  formed,  which  closes  the  wound 
and  converts  the  small  comjiound  frac- 
ture thus  made  into  a  sim])le  one. 
The  drilling  causes  considerable  in- 
flammation, and  the  determination  of 
1)1(1(1(1  to  the  part  carries  with  it  the 
materials  for  osseous  repair.  This 
simple  operation  is  worthy  a  trial  in 
ununited  fractures,  even  though  sub- 
sequently a  more  serious  operation 
under  ether  might  become  necessary. 
The  operations  fiir  non-union  in 
fractures  where  drilling  has  failed 
consist  of  cutting  down  upon  the  site 
of  the  fracture  and  exposing  the  false 
joint.  Great  care  should  be  exercised 
to  avoid  wounding  any  of  the  import- 
ant vessels  and  nerves.  The  inter- 
vening fibrous  tissue  should  now  be 
cut  away,  the  two  ends  of  the  bone 
brought  out,  and  a  small  piece  of  each 
end  sawed  otf,  so  as  to  .secure  a  fresh 
osseous  surface.  The  manner  of  further 
procedure  must  necessarily  depend  upon  whether  there  are  two  parallel 
bones  or  there  is  only  one  single  bone  in  the  extremity.  If  there  are 
two  bones,  no  union  can  be  effected  unless  a  corresponding  section  of 


w 


\V 


I 


COMPLICA  TIONS. 


539 


the  opposite  bone  is  removed,  in  order  to  have  tlie  broken  ends  brought 
in  apposition  (Fig.  45). 

Tliere  are  several  methods  of  fixation  of  the  exposed  fragments.     In 
some  cases  the  ends  can  be  sutured  by  silver  wire,  and  little  shortening 


Fig.  46. 


'J     u 

Volkmaun's  operation  for  pseudarthrosis. 

is  likely  to  follow.  .  In  other  cases  this  method  is  inapplicable,  since 
the  ends  are  often  too  pointed  to  afford  a  sufficient  breadth  of  surface 

Fig.  47. 


n.  H.  Smith's  splint  for  ununited  fracture  of  the  thi^^h. 

for  union.     Under  these  circumstances  the  jieriosteum  should  be  pre- 
served as  far  as  possible,  and  a  resection  be  made  in  each  fragment,  as 

Fig.  48. 


H.  H.  Smith's  splint  for  ununited  fracture  of  the  les. 

shown  in  Fig.  46.     The  fragments  can  be  fastened  together  by  ivory 
pegs  or  by  steel  nails,  or  even  sutured  by  strong  silver  wire. 

Palliative  measures  are  sometimes  indicated  where  an  operation  for 


540  FRACTURES. 

any  reason  seems  inadvisable.  The  aceompanying  cuts  illustrate  the 
principle  upon  whicli  sucli  treatment  is  based  (Figs.  47  and  48). 

In  extreme  cases,  where  tlie  limb  is  useless,  and  suppuration  is  present 
to  such  an  extent  as  to  endanger  life,  am})utation  may  be  called  for. 
Such  treatment  may  be  indicated  where  an  operation  to  effect  union 
has  failed  and  su])iiuration  and  necrosis  have  followed. 

It  occasionally  happens  that  no  operation  for  pseudarthrosis  is  per- 
missible, in  ^\hieli  case  a  splint  should  be  used,  so  that  the  patient  can 
have  a  greater  sense  of  security. 

Special  Fractures. 

Fracture  of  the  phalanges  occurs  as  a  i-esult  of  direct 
violence,  such  as  the  passage  of  a  wagon-wheel  over  the  toes  or  by 
the  fall  of  a  heavy  N\eight  directly  upon  the  ])art.  Fractures  of  the 
toes  may  also  be  caused  by  the  patient  striking  the  foot  against  a  chair 
or  sofa  while  walking  barefooted  in  the  dark.  If  the  fracture  is 
compound,  the  wound  can  be  dressed  aseptically  and  a  small  splint 
applied,  and  the  entire  foot  envelojied  in  a  plaster-of- Paris  bandage. 
The  soft  j>arts  are  very  vascular,  and  tlie  repair  is  very  ra])id  and  satis- 
factory. The  danger  from  tetanus  in  ccmijiound  fractures  of  the  toes 
must  not  be  overlooked.  In  the  sim])le  fracture*  of  the  phalanges  a 
pasteboard  splint  should  be  a])plicd  ^\•et  and  moulded  to  the  toe,  and  the 
foot  placed  in  a  plaster-of- Paris  bandage. 

Fractures  of  the  metatarsal  bones  occur  in  much  the  same 
way  as  those  of  the  phalanges,  only  the  degree  of  injury  inflicted  is 
greater.  The  same  general  rules  will  suffice  in  the  management  of 
fracture  of  these  bones. 

Fracture  of  the  tarsal  bones  occurs  from  direct  violence,  and 
is  usually  associated  with  great  destruction  of  the  soft  tissues.  The  skin 
is  very  apt  to  slough,  and  much  care  must  be  exercised  in  order  to  pre- 
serve the  integrity  of  the  tissues.  Fractures  of  the  scaphoid,  cuneiform, 
and  cuboid  bones  do  not  require  any  special  consideration  beyond  that 
exercised  in  the  general  management  of  fractures  of  the  metatarsal 
bones  of  the  phalanges. 

Fracture  of  the  calcaneum  usually  is  the  result  of  a  fall  from 
a  great  height  M-here  the  patient  strikes  upon  the  heel.  This  fracture 
has  occurred  a  number  of  times  in  workmen  on  elevated  railroads.  The 
men  in  endeavoring  to  avoid  a  passing  train  have  lield  themselves  sus- 
pended in  tiie  air  from  the  iron  structure,  and,  not  having  strength 
enough  to  hold  on  until  the  train  had  passed,  have  dropped  to  the  ground, 
and,  striking  ujion  the  hard  pavement,  have  broken  the  calcaneum  of  each 
foot.  The  fracture  may  also  be  produced  by  a  wheel  of  a  carriage 
or  cart  passing  over  the  foot  laterally  while  the  patient  is  lying  on  his 
side  upon  the  ground  (Fig.  49).  Fractures  of  the  calcaneum  may  occur 
from  muscular  action,  as  \\here  the  tendo  Achillis  is  suddenly  contracted 
and  tears  the  insertion  of  the  muscle  from  its  attachment.  The  detached 
tendon  often  carries  with  it  a  thin  shell  of  bone  from  the  posterior  part 
of  the  OS  calcis. 

The  signs  and  symptoms  of  fracture  of  the  calcaneum  are  such  as 
to  render  the  diagnosis  clear.     Crepitus,  pain,  swelling,  and  ecchymosis 


SPECIAL  FRACTURES. 


541 


are  present.  The  heel  itself  is  often  contnsed,  and  is  discolored  from 
the  bruise  caused  by  falling  upon  the  integument  over  the  heel.  The 
arch  of  the  foot  is  often  destroyed.  The  disjilacemcnt  varies  in  degree 
according  to  the  situation  of  the  fracture ;  thus,  if  the  break  traverses 


Fig.  49. 


Fracture  of  os  calcis. 

tlie  part  of  the  calcaneum  in  front  of  tiie  attachments  of  the  lateral 
ligament,  there  is  usually  but  slight  deformity,  since  the  strong  ealcaneo- 
astragaloid  ligaments  holds  the  fragments  in  situ.  On  the  other  hand, 
if  the  fracture  is  behind  the  insertion  of  the  lateral  ligaments,  the  tendo 
Achillis  dra\vs  the  posterior  fragment  well  up,  so  as  to  cause  a  marked 
and  characteristic  displacement.  The  dcn.se  fibrous  tissue  surrounding 
the  Ijone  also  helps  to  prevent  much  displacement. 

The  treatment  of  .fracture  of  the  calcaneum  varies  somewhat  accord- 
ing to  the  seat  of  fracture.  If  the  bone  is  broken  in  front  of  the  inter- 
nal lateral  ligaments,  the  den.se  fibrous  tissue  about  the  bone  and  the  sole 
of  the  foot  prevents  any  marked  dis])lacement.  The  foot  should  be 
placed  in  the  .^lightly  extended  position  and  a  plaster-of-Paris  bandage 
at  once  applied.  If  the  bone,  on  the  other  hand,  is  I)roken  behind  the 
insertion  of  the  lateral  ligament,  the  disi)lacement  is  well  marked,  and 
it  becomes  necessary  to  place  the  leg  upon  a  double-inclined  plane  in 
order  to  relax  the  tendo  Achillis,  which  causes  the  displacement.     In 


542  FRACTURES. 

the  treatment  of  tliis  fracture  division  of  the  tendo  Achillis  will  at  onee 
cause  the  deformity  to  disa])pear  and  the  fra<rnient  to  assume  its  natural 
jjosition.  Tlie  physiological  rest  thus  secured  will  result  in  rapid  repair 
of  the  fracture.  It  occasionally  happens  that  neither  the  use  of  the 
douhle-inelined  plane  nor  tenotomy  will  result  in  a  coaptation  and 
retention  of  the  fragments.  Under  these  circumstances  the  fragments 
can  be  wired  by  an  aseptic  operation,  or  an  ivory  peg  can  l)e  driven  into 
the  fragment  and  thus  fasten  it  firmly  to  the  bone.  If  the  fracture  is 
compound  and  the  fragments  are  loose,  it  is  best  to  remove  them,  since 
necrosis  of  the  small  detached  fragment  is  very  likely  to  follow. 

Fracture  of  the  astragalus  occurs  usually  at  the  neck,  since  this 
is  tlie  weakest  part  of  the  bone.  Fractures,  however,  are  found  through 
other  ])arts  of  the  bone,  and  also  associated  with  fractures  of  the  other 
tarsal  bones,  and  even  of  the  tibia  and  fibula.  Fracture  of  the  astrag- 
alus is  jjroduced  in  the  same  maimer  as  that  of  tlie  os  calcis,  excepting 
that  it  is  never  caused  l)y  muscular  action,  since  there  are  no  muscles 
attached  to  tlie  bone.  The  bone  is  sometimes  crushed  between  the  tibia 
and  the  os  calcis,  and  the  fracture  may  also  be  accompanied  by  a  fracture 
of  the  fibula  or  the  os  calcis,  or  even  with  a  dislocation  of  the  ankle- 
joint.  Generally  the  ordiuaiy  signs  of  fracture  are  present,  such  as 
crepitus,  pain,  tenderness,  and  inaliility  to  bear  pressure  on  the  bone. 
Tile  displacement  is  slight,  as  there  is  no  muscle  to  cause  traction  on  the 
fragment.  The  joint  is  often  inflamed  and  the  synovial  fluid  is  abiui- 
dantly  secreted,  so  as  to  destroy  the  landmarks  of  the  joint. 

The  treatment  of  this  fracture  is  often  fraught  with  difficulty,  since 
it  is  attended  with  more  or  less  synovitis.  This  comjtlication  is  best 
treated  by  fixation  of  the  joint  in  a  fracture-box  or  some  other  tempo- 
rary apparatus,  and  employing  an  e\'aporating  lotion  for  a  fcM'  days  until 
the  swelling  has  in  a  measure  subsided.  If  the  fragment  projects  under 
the  skin,  it  is  very  apt  to  cause  sloughing  of  the  soft  parts.  If  jjossible, 
the  fragment  should  be  pushed  back  in  its  ])lace,  even  if  it  requires  the 
employment  of  anesthesia,  for  which  nitrous  oxide  is  the  best  form  to 
use,  since  it  is  safe  and  lasts  a  sufticient  length  of  time  to  make  the 
adjustment.  If  the  projei'ting  fragment  will  not  resume  its  jjrojier  posi- 
tion, division  of  the  tendo  Achillis  will  enable  the  surgeon  to  reduce  the 
displaced  fragment.  The  danger  is  very  great  that  the  fragment  in  frac- 
ture of  the  astragalus  may  become  necrosed,  and  necrosis  be  followed  by 
suppuration  in  the  j(iint.  This  of  necessit)'  prepares  the  May  for  a  second- 
ary resection  of  the  joint. 

After  the  swelling  has  subsided  the  leg  can  be  placed  in  lateral 
splints  with  rectangular  foot-pieces,  and  thus  maintained  until  the  frac- 
ture unites.  A  plaster-of-Paris  bandage  or  felt  or  leather  splints  can 
be  used  with  cotton.  The  foot  should  be  placed  at  a  right  angle  to  the 
leg,  and  there  should  be  no  inversion  or  eversion  of  the  sole.  If  the 
fracture  of  the  astragalus  is  compound,  the  fragment  not  only  should 
be  at  once  removed,  but  the  wound  and  the  joint  irrigated  with  a 
weak  antiseptic  solution.  It  is  important  to  introduce  the  drainage-tube 
entirely  through  and  across  the  joint,  since  its  employment  with  only  one 
outlet  is  sure  to  be  followed  by  serious  after-effects.  The  anatomical 
arrangement  of  the  joint  is  such  that  ordinary  drainage  is  insufiicient  to 
meet  the  requirements  of  the  case,  and  special  emjjhasis  is  placed  ujjon 


SPECIAL  FRACTURES.  543 

free  and  complete  bilateral  drainage  secured  by  a  tube  pas.sina:  straight 
across  from  one  malleolus  to  the  other  and  placed  in  the  most  dejiendent 
portion  of  the  joint.  Great  care  should  be  exercised  not  to  begin  passive 
motion  for  at  least  three  weeks,  and  active  motion  not  sooner  tluui  five 
weeks.  There  is  no  doul>t  that  tiie  bad  results  after  this  fracture  are  due 
to  incomplete  drainage,  to  imperfect  antisepsis,  to  improper  splints,  to  the 
adoption  of  too  early  passive  motion,  and,  finally,  to  the  employment  of 
active  motion  before  the  ])roper  time  has  arrived. 

The  question  of  incision  into  the  joint  in  a  case  of  simple  fracture 
of  the  astragalus,  with  a  view  to  removing  the  fragment,  is  one  about 
which  no  unanimity  of  opinion  exists.  Some  surgeons  prefer  to  wait 
and  let  Nature  make  the  expulsion  of  the  fragment,  and  not  to  interfere 
until  suppuration  ensues,  while  others  believe  that  with  the  aid  of  anti- 
septic surgery  a  bold  operation  should  be  essayed.  No  general  law  can 
be  laid  down,  and  each  case  must  be  treated  on  its  individual  merits. 

Fractures  of  the  leg  may  be  classified  into  four  groups:  Frac- 
tures of  the  tibia  and  hlnda,  of  the  tibia,  of  the  filnda,  and  epiphyseal 
separations. 

Fractures  of  the  leg  form  about  1(3  per  cent,  of  all  fractures.  They 
are  rare  in  inf  incy  and  during  childhood,  but  between  the  ages  of  thirty 
and  sixty  the  greatest  number  t)f  fractures  of  the  leg  are  found.  Fractures 
of  the  leg  are  usually  the  result  of  direct,  although  they  may  be  caused 
by  indirect,  violence,  or  even  l\y  muscular  action.  As  a  rule,  the  direction 
of  the  fracture  in  the  lower  part  is  oblique,  while  in  the  upper  extremity 
of  the  limb  the  fractures  are  transverse. 

At  the  outset  too  much  stress  cannot  be  placed  upon  the  importance 
of  so  lifting  the  broken  leg  as  to  ensure  absolute  certainty  against  the 
conversion  of  a  simple  into  a  compound  fracture.  The  patient  should 
first  be  instructed  to  relax  the  muscles  of  his  broken  leg,  and  on  no 
account,  no  matter  how  severe  the  pain  is,  to  contract  his  muscles  so  as 
to  resist  the  assistarit  whose  duty  it  is  to  raise  the  limb.  Ha^'ing  fully 
explained  the  importance  of  this  to  the  patient,  the  assistant  should  grasp 
the  foot  at  the  juncture  of  the  phalanges  with  the  metatarsal  bones,  and 
make  gradual  extension  in  the  long  axis  of  the  limb  before  attempting 
to  raise  it.  As  soon  as  the  fracture  is  reduced  he  should  lift  the  leg 
slowly  from  the  bed.  In  this  manner  no  accident  can  follow,  and  the 
pain  consequent  upon  this  necessary  manipulation  is  very  slight. 

Fractures  of  the  tibia,  and  fibula  occur  by  direct  violence  in  the  great 
majority  of  cases.  They  may,  however,  result  from  indirect  violence  or 
even  by  muscular  action.  They  are  produced  by  heavy  weights  falling 
upon  the  limb,  by  the  kick  of  a  horse,  or  by  the  passage  of  a  car- 
wheel  or  heavy  truck  over  the  leg.  When  both  of  the  bones  of  the  leg 
are  broken  by  indirect  violence,  the  tibia  is  fractured  lower  than  the 
fibula.  This  is  probably  due  to  tlie  fact  that  the  tibia  is  broken  first,  and 
the  fibula  then  gives  way  upon  a  higher  level. 

The  signs  and  symptoms  of  fracture  of  the  tibia  and  fibula  need  no 
special  description,  since  they  are  most  marked  in  this  special  fracture. 
The  irregularity  of  the  line  of  the  tibia  is  often  a  most  important 
diagnostic  sign.  The  displacement  in  fracture  of  both  bones  of  the  leg 
needs  special  consideration.  The  lower  fragment,  with  the  foot,  is  drawn 
upward  and  backward  behind  the  upper  fragment  by  the  action  of  the 


544 


FRACTURES. 


Fig.  50. 


Fracture-box,  with  movable  sides. 


(ing.     It  is  axiomatic  in  fractures  tliat  tlio  sooner  a  broken 
n  a  permanent  splint  or  ban(lao;e  the  better  it  is  for  many 


gastrocnemius,  while  the  upper  fraojment  prnjei'ts  just  under  the  skin. 
Thei'e  are  likewise  abduction  of  tlie  foot  and  rotation  of  the  leg  out- 
ward, caused  by  the  weight  of  the  foot  and  of  the  lower  fragment,  owing 
to  the  loss  of  support. 

The  treatment  oi'a  simjile  fracture  of  Ixith  bones  of  the  leg  eonsi.sts  in 
the  application  of  a  suitable  retentive  a])]iaratus.     If  there  is  much  tension 

and  swelling  on  account  of  inflammatory 
exudation,  with  hemorrhage  and  blebs 
or  phlyctena',  the  limb  should  be  -placed 
in  a  fracture-box  ( Fig.  .50),  so  that  it  is 
surrounded  by  oakum  or  bran.  In  a  few 
days  the  swelling  subsides,  provided  the 
limb  has  been  kept  quiet  in  the  fracture- 
box.  The  phlyctenre  will  disappear  after 
they  have  been  simply  punctured  with  an 
aseptic  needle  and  a  small  piece  of  iodo- 
form gauze  placed  over  the  collapsed  vesicle.  If,  on  the  other  hand, 
there  is  no  marked  swelling,  and  no  blebs  upon  which  the  pressure  of  a 
splint  would  cause  .sloughing  exist,  the  limb  can  be  immediately  placed  in  a 
permanent  dre 
bone  is  placed 

reasons.  The  early  dressing  of  a  fracture  often  jtrevents  the  swelling  so 
frequently  found  where  there  has  been  delay  in  the  a])plication  of  a  ])er- 
manent  and  early  splint  or  bandage.  As  to  the  selection  of  a  special 
dressing  for  fractures  of  both  bones  of  the  leg,  the  opinions  of  surgeons 
are  at  variance.  The  writer  has  no  hesitancy  in  recommending,  with  the 
exception  nientioned,  the  inuiicdiate  use  of  plaster  of  I'aris  in  fractures 
of  both  Ixines  of  the  leg.  The  great  objection  raised  to  immediate  appli- 
cation of  the  plasti'r-of-Paris  bandage  is  the  danger  of  gangrene  from 
pressure  due  to  swelling.  The  writer  has  seen  this  unfortunate  accident 
occur  on  several  occasions  in  the  hands  of  well-known  surgeons ;  but  it 
is  certain  that  the  gangrene  was  not  due  to  the  use  of  the  plaster-of-Paris 
bandage  per  .sc,  but  to  the  improjier  and  careless  use  of  it.  The  writer 
has  also  seen  a  case  of  fracture  of  both  bones  of  the  leg  in  which  plaster 
of  Paris  was  immediately  applied,  and  the  entire  limit  became  one  ma.ss 
of  sloughing  material  concealed  under  the  bandage,  Avhile  the  septietemia 
resulting  from  this  condition  gave  rise  to  the  incorrect  diagnosis  of  typhoid 
fever,  from  which  sujjposed  cause  the  patient  died,  but  the  incidental 
removal  of  the  ]>laster  bandage  at  the  dead-house  revealed  the  true  cause 
of  the  septica'mia. 

The  manner  of  applying  a  plaster-of-Paris  liandage  (Fig.  •'Jl )  is  fully 
described  elsewhere,  but  the  special  points  in  connection  with  the  manage- 
ment of  this  particular  fracture  are  first  the  use  of  a  thick  layer  of 
absorbent  cotton  which  will  yield  to  any  .swelling,  and  thus  prevent 
the  danger  of  gangrene  ;  and,  second,  the  use  of  strips  of  jterfoi'ated 
tin  or  zinc  placed  over  the  limb  to  give  uniform  support,  and  thus  to 
obviate  the  necessity  for  a  heavy  bandage.  These  strips  should  be  fitted 
to  the  sound  limb,  and  then  placed  laterally  in  front,  and  along  the 
posterior  part  of  the  broken  leg,  and  bent  around  the  heel  .so  as  to  prevent 
any  backward  displacement  of  the  limb  during  the  repair.  Great  imjiort- 
ance  is  to  be  attached  to  this  posterior  splint.     As  a  matter  of  precaution 


SPECIAL  FRACTURES.  545 

the  toes  should  be  examined  after  six  hours  to  see  if  they  are  numb  or 
if  there  are  any  signs  of  obstructed  circuhition,  in  whicii  case  tlie  splint 
should  be  immediately  cut  off  and  a  new  one  applied.  At  the  expira- 
tion of  eight  days,  if  everything  lias  proceeded  favorably,  a  new  splint 
should  be  applied.     In  another  week  the  bandage  should  be  removed  to 

Fig.  51. 


Leg  encased  in  plaster-of-Paris  bandage. 

inspect  the  fracture,  since  occasionally  the  fragments  become  disturbed 
under  the  l)andage,  and  at  this  time  they  can  be  readjusted  when  later  it 
would   be   impo.ssible. 

If  the  surgeon  prefers  a  .splint  instead  of  the  pla.ster-of- Paris  bandage, 
the  classical  double-inclined  plane  of  Mclntyre  is  one  in  common  use. 
Where  there  is  much  deformity  and  the  fracture  is  not  easily  retained  in 
apposition,  this  splint  is  useful,  since  it  relaxes  the  mn.scles  of  the  calf 
by  flexion  of  the  knee.  In  some  cases  of  oblicpie  fracture  this  splint  is 
not  well  ada])ted  to  meet  the  emergencies  of  the  case,  as  it  does  not  over- 
come the  tendency  to  rotation,  and  also  because  in  flexion  of  the  knee  the 
quadriceps  extensor  muscle  of  the  thigh  has  a  tendency  by  its  contraction 
til  tilt  forward  the  lower  end  of  the  upper  fragment. 

Hahsted's  sliding  splint  is  most  excellent  when  there  is  any  tendency 
for  the  upper  fragment  to  jjrotrude.  The  writer  has  employed  in  certain 
cases  the  ordinary  fracture-bo.x  with  the  addition  of  a  weight  and  pulley 
to  the  lower  fragment.  After  the  leg  has  been  placed  in  the  fracture- 
box,  which  is  filled  with  bran  or  oakum,  with  the  movable  sides  turned 
down,  a  pad  is  placed  under  tlie  tendo  Achillis,  and  the  sides  are  now 
closed  up,  leaving  the  vertical  foot-piece  flat.  In  cases  where  there  are 
great  .swelling  and  a  tendency  fir  the  njipcr  fragment  to  protrude  through 
the  skin  this  dressing  is  fiund  most  useful. 

Nathan  R.  Smith's  iuiterior  sj)lint  (Fig.  52)  is  recommended  in  frac- 
tures of  both  bones  of  the  leg,  as  well  as  in  fractures  of  tlie  thigh. 

The  Bavarian  splint  is  excellent  if  the  fragments  can  be  kept  in  appo- 
sition without  artificial  extension  or  muscular  relaxation.  In  this  same 
category  may  be  mentidued  the  silicate-(if-soda  bandage,  the  lateral 
splints  of  leather  or  gntta-])ercha,  and  tlie  heavy  pasteboard  side-splints. 
In  the  use  of  any  of  these  side-splints  care  must  be  exercised  to  avoid 
the  tendency  of  the  backward  displacement  of  the  lowei-  fragment  with 
the  foot. 

Vol.  I.— 3j 


o4G  FRACTURES. 

The  writei'  cannot  too  highly  recommend  division  of  tlie  tendo  Aehil- 
lis  in  f'nictnres  of  botii  bones  of  tiie  leg  when  any  tendency  to  muscular 
spasm  or  to  marked  deformity,  or  any  ])rcnionitions  of  delirium  tre- 
mens, exist. 

Wliatever  dressing  is  em})loye(l,  the  surgeon  must  bear  in  mind  the 
fact  that  the  inner  side  of  the  ball  (jf  the  great  toe  must  be  brought  in 

Fig.  52. 


Nathan  R.  Smith's  anterior  splint. 

line  with  the  inner  edge  of  the  patella,  and  the  foot  maintained  at  a  right 
angle  to  the  long  axis  of  the  limb. 

In  fractures  of  the  n})per  part  of  the  leg  the  knee-joint  may  be  in- 
volved, and  then  hwmarthrosis  results,  \vhich  may  lead  to  serious  joint 
disease.  If  the  fracture  is  compoimd  or  complicated,  the  knee  must  be 
thoroughly  irrigated  and  drainage-tubes  inserted  into  the  sides  of  the 
joint,  since  the  open  wound  is  often  unsuitable  to  utilize  for  ])urposes 
of  drainage.  This  is  a  serious  operation,  and  nnist  be  performed  in  con- 
formity to  the  rules  laid  down  in  connection  with  compound  dislocations 
of  the  knee-joint. 

Fracture  of  the  tibia  is  of  more  frequent  occurrence  than  frac- 
ture of  the  fibula,  because  the  lione  is  less  protected  by  muscles  and 
receives  the  principal  weight  in  falling.  The  fracture  may  occur  at  any 
point  in  the  shaft,  but  the  junction  of  the  middle  with  the  lower  third 
is  the  more  frc(pient  seat,  since  this  jwrtion  is  anatomically  the  weakest 
part,  owing  to  the  fact  that  the  diameter  of  tlie  bone  is  less  at  this  place 
than  at  any  other  part  of  the  shaft.  In  this  jtart  the  jieculiar  anatom- 
ical arrangement  of  the  bony  columns  is  such  as  to  favor  fracture  upon 
the  receipt  of  indirect  violence.  The  bone  is  fractured  at  this  place 
often  by  torsion. 

Fractures  of  tlie  tibia  occurring  in  the  lower  part  of  the  bone  are 
usually  obli(jue  from  ai)oye,  downward  and  inward,  while  those  in  the 
upper  part  are  transverse.  The  fractures  in  the  lower  part  may  be  from 
direct,  but  usually  they  are  from  indirect,  yiolenec,  while  those  in  the 
upper  part  are  generally  produced  by  direct-  violence. 

Fractures  of  the  tibia  may  occur  at  the  lower  end,  through  the  shaft, 
or  at  the  upper  end. 

A  fracture  occurring  at  the  lower  end  of  the  tibia  usually  involves  the 


SPECIAL  FRACTURES. 


547 


Fracture  of  the 
internal  mal- 
leulus. 


internal  malleolus.  There  is  very  little  displacement,  because  the  inter- 
nal lateral  or  deltoid  ligament,  which  is  attached  as  well  to  the  borders 
as  at  the  apex  of  the  malleolus,  prevents  the  fragment  from 
becoming  detached.  This  injury  often  results  in  a  perma- 
nent ankylosis  of  the  ankle-joint  (Fig.  53). 

The  signs  and  symptoms  are  so  apparent  that  they  need 
no  special  tlescription. 

The  treatment  consists  in  placing  the  detached  fragment 
in  its  proper  position  and  retaining  it  by  the  use  of  com- 
presses placed  between  the  malleolus  and  the  inner  side  of 
the  splint.  It  is  highly  important  to  ha\c  the  fragment 
accurately  adjusted,  since  any  union  in  an  abnormal  position 
will  result  in  too  great  lateral  motion  to  the  astragalus,  and 
thus  render  the  patient  unable  to  walk  with  any  sense  of 
security.  If  the  fragment  cannot  lie  placed  and  retained  in 
its  proper  position  by  the  ordinary  measures,  the  operation 
of  cutting  down  upon  the  fragment  and  wiring  it,  or  of 
fixing  it  by  the  use  of  an  ivory  peg,  would  be  in  the  hands 
of  an  antiseptic  surgeon  a  just  procedure.  If  the  union 
is  fibrous,  it  is  a})t  to  interfere  with  the  free  movement  of 
the  ankle-joint. 

Fractures  of  the  shaft  of  the  tibia  are  not  attended  with  much  dis- 
placement, since  the  fibula  acts  as  a  side  splint  to  keep  the  parts  in 
apposition.  In  some  cases  the  only  signs  that  are  present  are  fixed 
pain,  localized  tenderness  on  pressure,  ecchymosis,  a  tendency  to  back- 
ward displacement,  a  slight  irregidarity  upon  jKissing  the  finger  down 
the  tibia,  as  well  as  an  irregularity  upon  the  surface  of  the  bone.  If  the 
fracture  hapjiens  to  be  in  the  lower  third  of  the  tibia,  crepitus  may  be 
felt  by  gras])ing  the  foot  firmly  and  rotating  it. 

The  treatment  consists  in  the  application  of  side-splints  of  leather, 
pasteboarfl,  or  gutta-percha,  or  in  the  use  of  a  plaster-of-Paris  bandage 
applied  in  the  manner  already  descrilied. 

Fracture  of  the  upper  end  of  the  tiljia  is  usually  transverse  and  the 
result  of  direct  violence  in  consequence  of  which  the  soft  parts  are  more  or 
less  bruised  and  contused.  There  is  usually  but  little  displacement,  since 
the  transverse  direction  of  the  fracture  prevents  any  marked  deformity  ; 
if,  however,  the  fracture  is  oblique,  then  the  displacement  is  prominent. 
In  this  fracture  by  direct  violence,  where  the  bone  is  liroken  transversely, 
occasionally  a  T-fi'acture  is  found,  and  the  line  of  fracture  extends  verti- 
cally into  the  kn.cc-joint.  In  tliis  case  a  eonsiilerable  degree  of  deformity 
is  jiresent,  since  the  knee-joint  becomes  at  once  the  seat  of  acute  synovitis, 
produced  by  the  presence  of  blood  within  the  capsule  and  also  by  the 
direct  effects  of  the  trainnatism.  '  If  the  fracture  is  oblique,  the  leg  is 
defleetcd  to  one  side,  o)i])osite  to  the  direction  of  the  line  of  fracture. 

Tile  treatment  of  this  injury,  situated  in  the  up]ier  part  of  the  tibia, 
consists  not  onlv  in  the  iiianagemcnt  of  the  fracture  itself,  but  also  in 
attention  to  the  joint  complication.  It  must  embrace,  therefore,  a  plan  to 
reduce  the  infianimatory  joint  affection,  as  well  as  a  retentive  ajiparatus 
for  the  fracture.  If  the  displacement  is  considerable,  the  deformity  can 
be  best  overcome  by  the  use  of  Mclutyre's  (Fig.  54)  double-inclined 
])lane,   which  1)V   relaxing  the    hauistring  luuscles  prevents  any  move- 


548 


FRACTURES. 


ment  in  tlie  long  lower  fragment,  and  makes  this  fragment  conform 
to  the  upper  or  short  fragment.  The  action  of  the  quadriceps  extensor 
is  to  tilt  the  upjier  fragment  forward  in  case  too  great  flexion  of  the  knee 
is  allowed.  If  but  slight  deformity  exists,  the  fracture  can  be  com- 
pletely reduced  and  a  plaster-of-Paris  bandage  employed,  with  a  com- 


FiG.  54. 


Mclntyre's  splint,  modified  by  Listen. 

press  over  the  upper  fragment.  In  some  cases,  where  the  muscles  of 
the  calf  make  traction  on  the  lower  fi-agment,  tenotomy  of  the  tendo 
Achillis  will  often  overcome  any  tendency  of  the  upper  margin  of  the 
lower  fragment  to  override  the  lower  margin  of  the  upper  fragment. 
After  three  weeks  gentle  passive  motion  should  be  employed  in  order  to 
prevent  adhesions  in  the  knee-joint. 

At  the  beginning  of  the  treatment  it  may  be  neces.«ary  to  use  cold 
evaporating  lotions,  the  ice-bag,  or  Leiter's  coil  to  reduce   the   local 

Fig.  55. 


Mclntyre's  splint  ami  Salter's  swing. 


inflammatory  condition  of  the  joint.  In  all  fractures  of  the  leg  in 
^xhich  the  j>laster-of-Paris  bandage  is  employed  it  will  be  found  that 
a  suspension  apparatus,  such  as  Salter's  swing  (Fig.  55),  will  enable  the 
patient  to  keep  the  fragments  more  quiet  than  when  the  leg  rests  entirely 
upon  the  mattress. 


SPECIAL  FRACTURES. 


549 


Fig.  57. 


Fig.  58. 


Epiphyseal  separations  (Fig.  56)  occur  in  young  people  under 
twenty  years  of  age,  and  since  they  are  produced  in  the  same  way  as 
fractures,  and  present  the  same  sym])t()ms,  and  finally 
demand  the  same  treatment,  there  is  little  to  say  in 
connection  with  them  beyond  what  has  already  been 
said  in  relation  to  simple  fractures  of  the  bone  in 
these  localities.  If  the  epiphysis  is  separated  in  a 
child,  the  growth  of  tlie  bone  is  very  nuich  aflbcted, 
so  that  when  the  patient  has  attained  his  full  size 
the  injured  leg  is  much  shorter  tiian  the  opposite 
one.  This  shortening  must  be  relieved  by  the  use 
of  a  cork  sole  applied  to  the  shoe. 

The  treatment   should    be    the    same    as  for   a  Separati..ii  ..i  lUe  i.jw.r 

n       .  i>    ii        1  •  -ii  i.   ii  epiphysis  of  the  femur 

fracture  ot   the  lione  occnrruig  either  at  the  upper       (Bryant). 
or  the   lower  part  of  the  siiaft. 

Fracture  of  the  pibuea  may  occur  at  any  point,  but  there  is 
only  one  special  fracture  that  tleserves  separate  consideration.  This 
is  known  as  "  Pott's  fracture,"  and  consists 
of  a  fracture  of  the  fibula  about  three 
inches  above  tiie  external  malleolus,  with  a 
laceration  of  the  internal  lateral  or  deltoid 
ligament,  and  in  some  cases  a  slight  chip- 
ping off  of  the  tip  of  tiie  internal  malleolus 
at  or  near  the  insertion  of  tlie  ligament. 
This  fracture  is  pi'oduced  by  a  fall  ujion 
the  foot,  and  the  foot  is  twisted  (Figs.  57, 
58)  outward,  and  occasionally  there  is  a  sligiit 
dislocation  of  the  ankle-joint,  caused  by  the 
astragalus  rotating  upon  the  under  surface 
of  the  tibia.  In  some  cases,  besides  the 
lesions  just  mentioned,  the  foot  may  be  dis- 
located backward,  since  the    lateral  supports 

have  been  destroyed.  Displacemcut  m  Potfs  fracture. 

Tlie  treatment  ot  fracture  of  tlie  nbula, 
with  the  exception  of  Pott's  fracture,  is  extremely  simple,  since  the 
tibia  itself  acts  as  a  splint,  and  any  ordinary  dressing,  such  as  leather, 
pasteboard,  gutta-percha,  or  side-splints,  will  answer  every  purpose.  In 
Pott's  fracture  there  are  only  two  dressings  which  are  woi'thy  of  special 
consideration  :  the  first  being  a  plaster-of- Paris  bandage,  a|)plied  while 
the  foot  is  held  in  marked  inversion,  witii  the  addition  of  a  strong  poste- 
rior splint  of  perforated  ziiie,  which  is  moulded  first  to  the  sound  leg  and 
then  applied  to  the  broken  limb,  in  order  to  prevent  the  backward  dis- 
j)lacement,  a  deformity  .so  apt  to  follow  during  the  rejiair  of  this  frac- 
ture. The  otiier  dressing  is  that  known  as  Dupuytren's  (Fig.  59),  which 
consists  of  a  board  about  four  inches  in  width  and  of  sufficient  lengtli 
to  extend  from  the  popliteal  space  to  three  inches  l)elow  the  foot.  On 
the  fractured  leg  a  pad  is  placed  which  reaches  from  the  popliteal  s]>ace 
to  the  internal  malleolus,  with  a  thickness  of  one  inch  at  the  upper  end 
and  three  inciies  at  the  lower  end,  where  it  extends  to  the  tip  of  the 
internal  malleolus.  The  leg,  with  the  pad  applied,  is  now  laid  laterally 
upon  the   splint,   wliicli   is  maintained    by  means   of  a  few   turns   of  a 


550 


FRACTURES. 


roller  bandage  above  and  lielow.  The  application  of  the  lower  bandage 
eauses  adduction  of  the  foot,  which  relaxes  the  internal  lateral  ligament 
and  brings  the  fragments  in  correct  ajiposition.  The  limb  is  placed 
upon  the  side  with  the  splint  in  contact  with  the  bed. 


Fig 


IKipuytreirs  ;sj"lint. 

Fractitre  of  the  patella  demands  careful  consideration  on 
account  of  its  close  proximity  to  tiie  knee-joint,  and  also  in  consequence 
of  the  imperfect  way  in  which  the  fragments  usually  unite.  Fracture 
of  this  bone  occurs  in  about  2  per  cent,  of  all  fractures,  and  it  is  found 
more  frequently  in  the  male  than  in  the  female — in  the  proportion  of  about 
5  to  1.  The  period  of  most  frequent  occurrence  is  between  the  ages  of 
thii'ty  and  fiity.  If  the  fracture  occurs  in  extreme  okl  age,  it  is  very 
likely  to  be  found  in  the  female. 

Fracture  of  the  patella  is  caused  by  muscular  action  or  by  direct 
violence.  The  direction  of  the  fracture  may  be  transverse,  vertical, 
oblique,  or  even  stellate.  In  the  fracture  produced  by  sudden  and 
violent  muscular  contraction  the  transverse  variety  usually  oeem's.  When 
the  fracture  is  caused  by  direct  violence  the  direction  may  be  vertical, 
oblique,  or  stellate,  or  the  fracture  may  be  eonniiinuted.  The  fracture  by 
muscular  action  occurs  when  the  knee  is  in  the  position  of  semi-tlexion. 
When  the  joint  is  in  this  position  the  middle  portion  of  the  nnder  surface 
touches  the  anterior  surflice  of  the  condyle.  A  sudden  and  forcible  con- 
traction of  the  quadriceps  extensor  muscle,  which  acts  at  nearly  a  right 
angle  to  the  vertical  surtiiee  of  the  patella,  causes  it  to  snap,  just  as  a  stick 
is  broken  across  the  front  of  the  knee.  A  fracture  caused  by  nniscular 
action  is  complete,  and  has  also  associated  with  it  a  tearing  of  the 
aponeurotic  and  fibrous  coverings  of  the  bone,  as  well  as  a  laceration 
of  the  synovial  membrane  of  the  joint  and  a  rupture  of  the  prepatellar 
bursa.  In  consequence  of  the  peculiar  nature  of  this  injury  the  joint 
is  soon  filled  with  blood,  and  the  synovial  secretion  becomes  abundant 
as  a  result  of  the  irritating  pressure  of  the  blood-clots. 

In  fracture  of  the  patella  the  knee-joint  is  always  opened,  unless  the 
extreme  lower  end  of  the  patella  is  broken,  in  which  case  it  is  possible 
for  the  fracture  to  exist  without  the  joint  involvement.  Both  patellae 
may  be  fractured  by  muscular  action.  The  writer  has  seen  this  in  a  case 
of  an  insane  patient  who  suddenly  attenqited  to  sj)ring  out  of  a  window. 
This  accident  has  also  been  re])orted  as  the  result  of  sudden  extension 
of  both  limbs  during  the  performanct'  of  lithotomy  without  an  anaes- 
thetic. The  fracture  of  both  patellae  has  also  been  observed  in  a  patient 
who  attempted  to  save  himself  from  falling  backward  on  account  of  a 
misstep. 

Fracture  of  the  patella  caused  by  direct  violence  is  the  result  of 
sudden  force  applied  directly  to  the  bone,  such  as  a  kick  from  a  horse, 


SPECIAL  FRACTURES. 


551 


Fig.  do. 


a  blow  upon  the  anterior  .surface  of  the  bone,  or  a  fall  directly  upon 

the  front  of  the  knee-joint.     In  this 

fracture  there  is  more  injury  to  the 

soft  parts  about  the  joint,  alth<>u<;h 

usually  the  .separation   of  the  fray- 

nients  is  not  so  great,  on  account  of 

the  al)senc'e  of  muscular  contraction. 

This  fracture  produced  by  direct  yio- 

lence  is  often  compound,  and  also,  in 

some  cases,  connuinuted  (Fig.  (JO). 

The  signs  of  fracture  of  the  paiella 
vary  sonie\yhat  according  to  the  man- 
ner in  which  the  injury  occurred.  The 
history  of  a  fall  during  which  the 
patient  felt  a  sudden  snap,  or  of  a 
blow  upon  the  knee-joint  with  some 
instrument,  or  of  a  kick  by  an  animal, 
together  with  sudden  loss  of  p(jwer 
in  the  limb,  lengthening  of  the  patella 
Avith  a  well-marked   sulcus,  with  ec-  ,,  , ,    ,        ,     .  n 

.  .  -  .  -'  Cumpountl  frat'lure  of  i)atL'lla. 

chymosis  and  swelling  rapidly  appear- 
ing, with  a  loss  of  the  general  contour  of  the  joint, — are  characteristic 
indications  of  fracture  of  the  patella.  The  amount  of  separation  between 
the  fragments  depends  upon  the  (k\gree  of  muscular  contraction  at  the 
time  of  the  accident,  together  with  the  amount  of  synovial  secretion 
and  the  extent  to  whicli  the  lateral  attachments  of  the  patella  are 
lacerated,  and,  to  a  certain  extent,  u))on  the  contraction  of  the  liga- 
mentum  ])atell8e.  A  patient  has  been  known  to  walk  after  fracture  of 
the  patella,  but  this  is  a  most  unusual  eyeut.  C're])itus  is  generally 
absent  in  this  fracture,  on  account  of  the  separation  of,  and  the  inter- 
vention of  blood-clots  and  fibrous  tissue  between,  the  fragments. 

A  certain  amount  of  displacement  is  sometimes  found  after  the  fracture 
has  been  re])aired  ;  for  example,  the  fragments  may  be  displaced  to  the 
side  or  in  front.  The  lateral  displacement  is  caused  by  the  ligamentous 
or  fibrous  union  stretching  unequally,  while  the  anterior  dis])lacement  is 
due  to  the  pressure  of  pads  placed  above  and  below  the  fragments,  which 
causes  them  to  tilt  forward.  The  fragments  may  be  i)uslied  up  by  the 
underlying  fluid,  so  that  their  anterior  surfaces  are  not  on  the  same  plane. 

The  usual  mode  of  union,  to  which,  of  course,  there  are  exceptions, 
is  not  osseous,  unless  the  fracture  has  been  treated  by  opening  the  joint 
and  suturing  the  fragments  with  silver  wire.  The  question  as  to  whether 
bony  union  eyer  takes  jilace  In- the  older  method  of  treatment  is  settled 
without  any  doubt.  A  s])ecimcn  in  support  of  this  statement  is  fouii<l  in 
the  Wood  Museum,  where  the  union  is  by  bono  (Fig.  (H  ),  the  patient 
haying  been  treated  by  Dr.  Charles  Phelps.  The  medium  of  union 
where  the  fracture  has  been  subjected  to  the  ordinary  methods  of  treat- 
ment is  fibrous  tissue.  Occasionally  no  direct  union  occurs,  and  the 
fragments  are  siin])ly  held  in  contact  by  the  thickened  fibrous  capsule 
of  the  joint  and  the  snrrouii<ling  lateral  tissues  outside  of  the  joint 
(Fig.  (i2).  The  reason  why  a  transyerse  fracture  of  tlu^  ])atella  s(>l(lom 
unites  by  bone  is  that  at  the  tune  of  the  accident  the  fibrous  tissue  or  the 


552 


FRACTURES. 


capsule  of  the  anterior  .surface  of  the  patella  falls  down  between  the  frag- 
ments, and  thus  acts  as  a  foreign  body  and  prevents  the  coaptation  of  the 
bony  surfaces,  and  consequently  union  by  bone  is  rendered  imjiossible. 
The  treatment  of  fi-acture  of  the  patella  consists  in  the  aj)plicatioD 


Fic.  61. 


Fiu.  62. 


Osseous  union  after  a  fract\ire  of  patella.         Ligamentous  union  after  fracture  of  the  patella. 

of  a  suitable  a|)paratus  designed  to  bring  into  apposition  the  fragments. 
Some  special  mnnagenient  of  the  joint-infiammation  before  applying  any 
permanent  dressing  is  necessary.  There  have  been  pnblishe<l  innumer- 
able devices  to  meet  the  diiSiculties  surrounding  the  treatment  of  this 
fracture.  Concentric  pressure  causes  a  deficiency  in  the  blood-supply  ; 
the  small  size  of  the  fragments  often  cau.ses  them  to  tilt  upward,  and  the 
bulging  of  the  condyles  with  the  leg  extended  prevents  clo.se  apposition 
of  the  fragments ;  the  synovitis  and  ha;marthrosis  retard  the  union  by 
.separating  the  broken  surfaces;  and  many  other  causes  are  in  operation 
to  prevent  the  osseous  repair  of  this  fracture. 

Before  any  method  is  resorted  to  with  a  view  to  bringing  the  frag- 
ments into  apposition  the  surgeon  must  endeavor  to  control  and  modify 
the  joint-inflammation.  The  ice-bag  is  used  with  signal  benefit  during 
the  first  few  days,  after  wJiich  lead-and-opium  wash  can  be  a})plied. 
Cold  irrigation  is  sometimes  employed  instead  of  the  ice-bag,  and  in 
some  cases,  where  there  is  a  good  deal  of  superficial  ecchymosis,  a  \\arm 
fomentation  is  applied.  As  soon  as  the  heat  has  subsided  gentle  uni- 
form compression  with  sponges  can  be  em]iloyed  around  the  joint,  with  a 
view  to  promoting  absorption  of  the  fluid  in  tiie  joint.  IJlistei's  have  been 
suggested,  but  their  use  is  attended  by  so  much  inflammation  of  tiie  .skin 
as  to  prevent  the  application  of  any  apparatus.  After  the  expiratitin  of 
a  week  the  joint-complication  should  be  sufficiently  controlled  to  allow 
the  application  of  some  permanent  dressing.  The  limb  can  be  so  placed 
that  position  alone  affords  an  excellent  method  of  treatment.  Home 
surgeons  simply  place  the  limb  on  a  splint  and  elevate  the  heel,  so  that 
the  foot  is  from  two  to  three  feet  abo\e  tiie  foot  of  the  l)ed  ;  and  in  this 
way  the  rectus,  crureus,  and  vasti  are  relaxed,  so  that  tiiere  is  no  traction 
upon  the  upper  fragment.  With  a  view  of  still  furtiier  relaxing  the 
muscles  the  ])atient  can  be  jirojiped  up  on  a  bed-rest.  If  now  the  entire 
limb  is  bandaged    and  then  the    limb    is  bandaged  to  the  splint,  the 


SPECIAL  FE.WTVEES.  553 

essential  condition  of  the  treatment  is  fultilled.  Without  doubt  tliis 
metiiod  has  met  witli  excellent  success,  but  in  the  event  of  failure  to 
secure  a  satisfactory  result  a  surgeon  might  be  exposed  to  criticism  on 
the  part  of  the  patient,  which  might  be  an  opening  wedge  for  a  law- 
suit for  damages. 

Another  plan  has  been  suggested,  which  is  likewise  liable  to  result  in 
an  unsatisfactory  manner,  and  that  is  immediate  aspiration  of  the  knee- 
joint  and  tenotomy  of  the  quadriceps  extensor  nuiscle.  Tliis  plan  is  too 
bold  to  recommcntl,  since  in  some  cases  it  has  proved  most  disastrous  by 
provoking  a  suppurative  arthritis. 

Still  another  plan  has  been  suggested  by  Schede,  of  aspirating  the 
joint,  and  then  injecting  into  it  a  3  per  cent,  solution  of  carbolic  acid 
until  the  fluid  withdrawn  is  perfectly  clear,  and  at  once  applying  a  plas- 
ter-of-Paris  Ijandage.  This  operation  has  been  attended  in  some  cases 
by  suppuration,  and  in  others  by  secondary  amputation,  pya?mia,  and 
death.     This  plan,  therefore,  has  not  been  received  with  favor. 

The  ap])aratus  that  seems  best  to  meet  tlie  difficulties  of  the  case 
consists  of  plaster-i)f-Paris  compresses  applied  with  or  without  a  figure- 
of-8  bandage.  A  compress  can  be  placed  just  above  the  upper  margin 
of  the  upper  fragment,  and  then  with  a  strip  of  rubber  plaster  about 
eighteen  inches  in  lengtli  and  one  inch  in  width  the  compress  can  be 
fixeil  and  the  fragment  drawn  down  by  liringing  tlie  strips  downward 
under  the  calf  of  the  leg.  Another  compress  is  placed  just  beneath  tlie 
lower  margin  of  the  lower  fragment,  and  the  compress  held  in  place  by 
a  similar  strip  of  plaster,  which  runs  upward  under  the  thigh.  These 
two  strips,  crossing  each  other  upon  the  outer  and  inner  sides  of  the 
joint,  cause  the  fragments  to  come  in  close  apjiosition.  A  third  com- 
press is  placed  over  the  entire  fractured  patella,  so  as  to  prevent  the 
tilting  upward  of  the  fractured  ends.  This  dressing  must  l)e  frequently 
changed,  since  the  plaster  is  likely  to  slip,  and  each  day  the  knee-joint 
becomes  less  in  diameter,  owing  to  the  absorption  of  the  fluid  in  the 
joint.  The  limb  can  now  be  placed  upon  an  inclined  jjlane,  and  the  leg 
and  the  thigh  fastened  to  the  splint  by  a  few  rollers  of  plaster-of-Paris 
bandages. 

Dr.  Little  employed  a  similar  apparatus  in  which  the  adhesive  plaster 
was  omitted  and  a  wet  plaster  roller  in  the  form  of  a  figure  of  8  was 
applied  in  the  same  manner  as  the  adhesive  plaster  already  described,  and 
while  the  plaster  was  wet  the  finger  and  thumb  of  one  hand  indentated 
the  plaster  above,  and  the  finger  and  thumb  of  the  other  hand  likewise 
indentated  the  wet  plaster  bandage  on  the  lower  fragment.  The  frag- 
ments were  thus  pressed  together  and  p^^,  gg 
firmlv  held  until  the  plaster  had  finally 
"set." 

Malgaignc  em]iloyed  a  pair  of  dou- 
ble hooks  (Fig.  G3),  the  ])oints  of  which 
passed  tlirough  the  integument  and 
pierced  the  upper  and  lower  fragments. 
The  hooks  were  now  brought  close  to- 
gether bv  means  of  a  screw  until  the  

Y  >  •  ^   i-  rr<i  Malgaigne  s  hooks. 

bony  surfaces  were  in  coaptation.      1  lie 

method  is  an  ideal  one,  and  the  most  satisfactory  results  have  been  obtained 


554 


FRACTURES. 


Fic.  64. 


by  these  liooks,  hut  it  is  seldom  that  a  jiatient  will  endure  the  ])ain  and 

discoini'urt  which   tiiey  produce. 

Levis  improved  tiie  nietliod  In'  using  a  douhie  jiair  ofdouhle  hooks  (Fig. 
64),  which  are  j)laced  obliquely  ;  while  Trelat,  to 
overcome  the  objection  of  pain,  substituted  gutta- 
percha plates  heated  in  a  flame  and  accurately  ad- 
justed to  the  fragments,  and  into  these  plates  the 
hooks  arc  inserted  (Fig.  65). 

Hamilton's  metiiod  "consists  of  a  single  inclined 
plane  of  sufficient  length  to  support  the  thigh  and 
leg,  and  about  six  inches  wider  than  the  limb  at  the 
knee.  This  plane  rises  from  a  lioi'izontal  floor  of 
the  same  length  and  breadth,  and  is  suj^jiorted  at 
its  distal  end  by  an  upright  piece  of  board  which 
serves  both  to  lift  the  ]>lane  and  to  su])port  and 
steady  the  foot.  The  distal  end  of  the  inclined 
plane  may  be  elevated  from  six  to  twelve  inches 
according  to  the  length  of  the  limb  and  to  other  cir- 
cumstances. Upon  either  side,  about  four  inches 
below  the  knee,  is  cut  a  deep  notch.  The  foot- 
piece  stands  at  right  angles  with  the  inclined  plane, 
and  not  at  right  angles  with  the  horizontal  floor. 
Having  covered  the  ap])aratus  with  a  thick  and  soft 
cushion  carefully  ada])ted  to  all  the  irregularities 

of  the  thigh  and  leg,  especial  care  being  taken  to  fill  completely  the  space 

under  the  knee,  the  whole  limb  is  now  laid  upon  it,  and  the  foot  gently 


Levis's  modification  in 
place. 


Fig.  65. 


Trtlat's  dressing  for  fracture  of  patella. 

secured  to  the  foot-board,  between  wliich  and  the  foot  another  cushion  is 
placed.  The  body  of  the  patient  should  also  be  flexed  upon  the  thigh,  so 
as  the  more  cflectiially  to  relax  the  (juadricejis  femoris  muscle.  A  roller 
is  now  apjjlied  to  the  knee  by  obliipic  and  circular  turns,  commencing 
above  the  ]>atella,  and  traversing  the  notch  in  the  .sjilint,  each  successive 
turn  covering  more  of  the  front  f)f  the  knee  until  the  whole  is  enclosed. 
With  a  second  roller  the  entire  liml)  must  then  be  secured  to  the  splint, 
this  roller  extending  from  the  ankle  to  the  groin  "  (Fig.  66). 

Agnew's  method  consists  of  "  a  piece  of  sjilint  somewhat  convex 
longitudinally,  on  the  upper  surface  thirty  inches  long  and  five  inches 
wide  at  one  end,  tapering  to  foiu-  inches  at  the  other.     On  each  side,  a 


SPECIAL  FRACTURES. 


555 


short  distance  above  and  lielow  the  middle  of  the  lioard,  are  to  be  bored 
two  holes,  into  which  are  litted  four  pegs  with  square  heads  (Figs.  67, 


Fig.  06. 


68).  This  s]:)lint  must  be  well  padded  and  jilaeed  under  the  thigh  and 
the  leg,  the  limb  being  at  the  same  time  moderately  elevated.  Below 
the  knee  and  the  lower  fragment  are  next  to  be  a[)plied,  partially  over- 


FiG.  67. 


Asnew's  splint  for  fracture  of  the  patella. 


lapping  each  other,  two  or  three  strips  of  adhesive  plaster,  each  three- 
quarters  of  an  inch  wide  and  thirteen  inches  long.  These  .strips  are 
brought  together  at  their  extremities  and  wrapped  around  the  upper 


Fig.  68. 


,,j|iJijiiji3l)i)pi%;ith 

Agnew's  splint  applied. 

pegs.  This  .secures  in  position  the  lower  fragment.  Five  strips  of 
plaster  of  like  length  and  width  are  next  a])])lied  three  or  four  inches 
above  the  knee,  descending  toward  the  joint,  each  strip  overlapping  one- 


556  FRACTURES. 

tliird  of  the  preceding  one.  Bringing  tlie  ends  of  the  plaster  together, 
lliey  are  to  be  M'ound  around  the  lower  pin,  when,  by  screwing  or  twist- 
ing the  pegs  of  the  two  sides,  the  lower  fragment  will  be  l)rf)ught  into 
near  apposition  with  the  upper.  To  prevent  the  broken  surfaces  from 
tilting  forward  a  broad  strij)  of  plaster  may  be  drawn  over  the  line  of 
approximation  and  fastened  to  the  splint  l)elow.  A  roller  is  now 
applied  above  and  below,  which  secures  the  thigh  and  leg  to  the  splint 
(Fig.  (58).  As  the  swelling  subsides  all  that  is  necessary  to  maintain 
the  adjustment  is  to  tighten  the  strips  by  screwing  up  the  pegs  to  which 
they  are  fastened.  By  this  plan  the  removal  of  the  dressing  is  ren- 
dered unnecessary  until  the  cure  is  complete.  Between  the  third  and 
fourth  weeks  the  strijjs  may  be  separated  from  the  jiins,  the  knee  gently 
moved  so  as  to  overcome  stiffening,  and  the  dressing  again  adjusted. 
This  process  should  be  repeated  every  five  or  six  days  until  the  fifth 
week,  \\-hen  the  splint  may  be  laid  aside  and  the  patient  be  placed  on 
crutches."  ' 

Wiring  the  patella  is  an  operation  which  within  a  few  years  lias  been 
brought  prominently  into  notice,  especially  through  the  labors  of  Dr. 
Charles  Phelps.  The  operation  is  one  about  which  much  honest  diver- 
sity of  opinion  exists.  The  arguments  in  favor  of  the  operation  are  the 
absence  of  great  danger  to  life  and  limb,  the  superior  results  as  regards 
the  function  of  the  joint,  and  the  greater  rapidity  of  repair.  In  refer- 
ence to  the  danger  to  life,  it  may  be  stated  that  Dr.  Phelps  reported  (in 
1890)  111)  cases  of  wiring  the  patella  in  New  York  City,  in  wliich  there 
was  no  death  directly  attributed  to  the  operation,  and  but  one  death  due 
to  delirium  tremens — a  complication  tliat  would  have  occurred  in  any 
other  operation.  In  the  hands  of  a  thorough  aseptic  surgeon  the  danger 
to  life  from  sepsis  is  insignificant.  The  superior  results  as  regards  the 
function  of  the  limb  are  demonstrated  by  the  invariable  presence  of 
bony  union  and  a  freely  movable  joint.  The  rapidity  and  completeness 
of  repair  is  made  evident  when  it  is  considered  that  ]iatients  have 
walked  well  within  three  weeks  after  the  ojieration,  have  walked  a  mile 
within  six  weeks,  and  later  on  have  played  football. 

On  the  other  hand,  some  surgeons  claim  that  the  operation  is  too  seri- 
ous, and  that  results  which  are  sufficiently  satisfactory  can  be  obtained 
by  less  severe  measures.  Tlie  author  feels  justified  in  recommending 
the  operation  in  cases  where  there  is  no  organic  disease,  when  every  pos- 
sible antiseptic  precaution  can  be  secured,  and  M-here  the  2)ers<inal  cir- 
cumstances of  the  patient  make  it  an  object  to  assume  a  minimum  of 
risk  for  a  maximum  of  good.  It  is  a  serious  matter  if  a  laboring-man 
with  rent  to  pay  and  children  to  feed  and  clothe  must  remain  idle  for 
three  months,  and  then  be  practically  incajiacitatcd  for  hard  work  for 
eighteen  months,  instead  of  resuming  work  witliin  two  months  from  the 
time  of  the  accident.  The  question,  however,  of  wiring  the  patella  must 
rest  upon  the  individual  circumstances  in  each  case,  since  no  rule  M'hich 
is  universal  can  be  formulated. 

In  investigating  the  history  of  this  operation  it  is  ascertained  that 
Rhea  Barton  in  1834,  McClellan  in  1838,  Cooper  in  1861,  and  later 
Logan  and  Green,  wired  the  patella.  All  (if  tliese  operations,  successful 
and  unsuccessful,  were  performed  at  a  period  mIucIi  antedates  Cameron's 

'  Agnew's  Surgery,  vol.  i.  p.  974. 


SPECIAL  FRACTURES.  557 

sug'gestion  and  practice  nearly  forty  years,  and,  tliousih  tlie  principle 
U])tin  which  the  operation  is  now  performed  is  widely  ditt'erent  fi-oni  that 
wiiich  inspired  the  early  pioneers  in  American  surgery,  yet  tiie  fact  is 
that  here  this  operation  was  conceived  and  born,  but  in  Scotland  it  has 
developed. 

Wiring  the  patella  should  not  be  performed  inunediately  after  the 
accident,  as  inflammatory  action  is  likely  to  follow  the  receipt  of  the 
injury.  It  is  wise  to  wait  eight  or  ten  days  until  the  jjarts  are  in  better 
condition.  In  case  the  fracture  is  compound,  tlie  operation  siiould  be  per- 
formed without  delay.  Before  wiring  tlie  fragments  of  a  fracture  of  tlie 
patella  the  entire  limb,  including  die  foot,  should  be  thoroughly  scrubbed 
and  washed  with  soap  and  iiot  water,  after  which  ablution  the  jiarts  should 
be  carefully  washed  in  a  solution  of  bichloride  of  mercury  of  about  the 
strength  of  1  :  2000.  Over  the  joint  itself  a  saturated  solution  of  iodo- 
form in  ether  or  of  naphthalin  in  ether  should  be  poured.  Tiie  parts 
above  and  below  the  joint  are  surrounded  and  enveloped  by  towels  satu- 
rated in  a  solution  of  liidiloride  of  mercury  of  the  strength  of  1  :  2000. 
The  opposite  leg  is  covered  by  wet  towels,  and  the  parts  are  in  readiness 
for  the  surgeon.  From  the  beginning  to  the  end  of  the  operation  con- 
tinuous irrigation  of  the  interior  of  the  joint  is  kept  up  with  a  1  :  10,000 
solution  of  bichloride  of  mercury.  It  is  unnecessary  to  add  that  tlie  ope- 
rator and  iiis  assistants  are  thoroughly  disinfected,  and  all  instruments, 
wire,  sutures,  ligatures,  and  sponges  are  pre])ared  with  the  greatest  care. 
The  incision  can  be  either  longitudinal,  transverse,  or  crucial.  The 
transverse  incision  is  preferred,  though  the  longitudinal  is  tlie  one  more 
frequently  eni]iloyed.  The  fragments  and  the  joint  are  freely  exposed, 
and  all  blood-clots  from  the  joint,  from  the  synovial  jiouch  under  the 
quadriceps  extensor  muscle,  and  from  between  the  fragments  are  removed. 
The  two  fragments  are  refreshed  by  being  scraped  m  itli  a  Heber  scoop, 
and  the  intervening  tissue,  consisting  of  the  anterior  fibrous  capsule,  is 
elevated  from  between  the  fragments.  The  Arciiimedean  drill  is  now 
made  to  perforate  the  upper  fragment,  and  then  the  lower  fragment,  care 
being  taken  to  have  the  point  of  the  drill  emerge  from  the  lo\ver  surface 
of  the  patella  just  above  the  lower  cartilaginous  surface.  In  case  one 
fragment  is  very  small,  it  should  be  drilled  first,  so  as  to  bring  it  into 
better  ajiposition  with  the  larger  fragment.  The  bottom  of  tiie  .synovial 
pouch  is  felt  upon  its  outer  side,  and  an  opening  made,  through  which  a 
red-rubber  drainage-tube,  which  contains  no  free  sulphur,  is  inserted  into 
the  cavity  of  the  joint.  This  tube  should  be  removed  in  three  or  four 
days,  although  Fowler  has  demonstrated,  in  his  wonderfully  successful 
case  of  eomiiound  fracture  of  the  ])atella,  that  it  is  juissible  to  allow  the 
tube  to  remain  two  weeks  with  impunity.  The  wire,  which  should  be  of 
silver,  is  of  moderate  thickness,  and  is  twisted  and  cut  off  and  hammered 
down  upon  and  into  the  tissues  over  the  line  of  fracture.  Experience 
shows  that  no  harm  ever  results  from  burying  the  wire  in  the  tissues  of 
the  wound.  The  a])oneurotic  fascia  and  soft  tissues  in  front  of  the  jiatella 
are  now  nicely  sutured,  which  procedure  hermetically  seals  in  twenty-four 
hours  the  front  of  the  joint  from  anv  serous  discharo'e  infiltratin<r  tlirouirh 
the  fissure  made  by  the  fracture  from  the  soft  parts  over  the  front  of  the 
patella.  All  loose  pieces  of  tissue  are  removed  and  any  torn  or  lacerated 
shreds  are  cut  away  by  a  pair  of  scissors.     The  integument  is  now  sutured 


558  FRACTVBES. 

and  tlie  line  of  incision  is  closed.  The  linear  incision  can  be  ])ainted  over 
with  a  layer  of  styptic  collodion  and  tiien  dusted  over  with  iodoform  or 
naplithalin.  A  posterior  splint  is  now  adjusted,  and  a  regular  plaster-of- 
Paris  sj)lint  is  applied  over  tlie  layers  of  antiseptic  dressings.  At  the 
expiration  of  three  days  the  tube  is  removed  througli  a  i'enestra  cut  in  the 
splint.  Instead  of  a  plaster-of- Paris  splint,  a  wire-netting  splint  is  used 
by  some  surgeons.  The  patient  is  now  kept  in  bed,  though  he  can  sit  up 
very  soon  after  the  operation,  and  the  first  dressing  should  be  removed 
in  the  course  of  the  first  week.  In  four  weeks  he  can  be  allowed  to  get 
up  from  his  bed,  and  shortly  after  walk  about  the  ward.  Massage,  sham- 
jiooing,  friction,  electricity,  and  gentle  }>assive  motion  will  soon  restore 
the  joint  to  its  jJerfect  function. 

The  conclusions,  after  a  careful  analysis  and  study  of  all  the  reported 
and  as  many  unrej)orted  cases,  are  these  : 

In  compound  fractures  of  the  ])atella  there  is  not  the  slightest  question 
as  to  the  ])ropriety  of  the  operation  of  wiring  the  fragments. 

In  recent  and  old  fractures,  with  the  facts  fully  presented  to  the  patient 
and  under  the  strictest  antise]itic  precautions,  the  operation,  in  the  light 
of  present  statistics,   is  wholly  justifiable. 

In  debilitated  patients  and  in  those  suffering  from  any  organic  disease 
the  operation  siiould  not  be  employed,  and  is,  in  fact,  contraindicated, 
as  are  all  other  o])erations  of  expedieu(y. 

It  is  not  an  operation  whieli  can  l)e  indiscriminately  performed,  and 
never  by  an  ordinary  practitioner  with  little  surgical  experience  and  with 
little  faith  in  the  germ-theory  of  inflammation. 

The  success  of  this  operation  depends  wholly  upon  conscientiously 
carrying  out  the  smallest  details  needed  to  secure  aseptieity,  and  the 
surgeon  ^vho  is  not  imbued  \\\i\\  the  true  spirit  of  antiseptic  surgery 
ought  not  to  ])erform  this  operation. 

While  the  number  of  cases  yet  operated  upon  is  too  limited  to  admit 
of  deductions  by  means  of  which  a  final  settlement  of  this  question  can 
he  made  in  the  minds  of  surgeons,  the  future  practice  of  the  surgery  of 
this  and  of  other  countries  will  soon  enable  us  to  condemn  it  as  an  unsafe 
and  unjustifiable  procedure,  or  else  it  will  be  conceded  as  one  of  the 
grandest  triumphs  of  our  art. 

Compound  fracture  of  the  patella  is  a  most  serious  accident.  Thei'e 
is  but  one  method  universally  recommended,  and  that  is,  under  the  influ- 
ence of  an  anaesthetic,  to  enlarge  the  original  wound,  irrigate  thoroughly 
the  joint,  drain  it  with  rubber  tubing,  and  wire  the  fragments  with  silver 
wire.  If  the  operation  is  performed  with  aseittic  precautions,  tiie  tubes 
can  be  removed  upon  the  third  day  and  the  wound  closed,  and  an  ideal 
result  secured.  This  injury  in  pre-antiseptic  days  was  usually  attended 
by  a  fatal  result,  but  with  the  application  of  the  principles  of  modern 
surgery  the  cases,  as  a  rule,  do  well,  and  the  final  result  is  perfect  as 
regards  the  restoration  of  the  function  of  the  joint. 

Fractures  of  the  Femur  form  about  6  jier  cent,  of  all  fractures. 
In  the  aged  they  occur  usually  in  the  upjier  third,  in  ciiililrcn  in  the 
middle  third,  while  in  adults  the  fractures  are  generally  found  in  the 
lower  third  of  the  bone.  Fractures  of  the  shaft,  however,  may  occur  at 
all  ages,  but  fractures  of  the  neck  of  the  thigh-bone  are  usually  found 
in  the  aged,  and  esj)ecially  in  women. 


SPECIAL  FRACTURES. 


559 


Fractures  of  the  temur  in  the  upper  third  may  be  classified  according 
to  the  seat  of  the  fracture  ;  thus,  intra-capsular  and  extra-capsular  frac- 
ture of  tlie  cervix  femoris ;  trochanteric  fracture  and  subtrochanteric 
fracture  of  the  shaft ;  in  the  middle  third  according  to  the  variety  of  the 
fracture  :  thus,  simple,  compound,  comminuted,  gunshot,  and  complicated 
fracture ;  in  the  lower  third  according  to  the  part  fractured  ;  thus,  exter- 
nal, internal,  and  supracondyloid  fracture  and  ej)iphyseal  separation. 

Epiphyseal  separation  is  an  injury  which  is  classified  with  fractures 
for  reasons  already  mentioned.  This  injury  occurs  before  the  twentieth 
year  of  life,  at  which  time  the  lower  epiphysis  unites  to  the  shaft,  and  any 
injury  of  the  lower  part  of  the  bone  occurring  as  the  result  of  accident 
or  during  an  attemj)t  to  lircak  up  ankylosis  of  the  knee  in  a  patient 
under  twenty  with  tiie  symptoms  of  fracture  suggests  a  separation  of 
the  epiphysis  from  the  diaphysis.  In  the  discussion  of  supracondyloid 
fracture  the  treatment  of  epiphyseal  separation  will  be  considered. 

Supracondyloid  fracture  occurs  about  two  inches  above  the  epiphyseal 
line,  and  is  usually  the  result  of  direct  violence,  as  a  blow  upon  the  side 
of  the  fenuir  or  a  l)low  upon  the  patella  while  the  knee  is  flexed.  The 
fracture  is  situated  at  the  point  where  the  cancellated  bone  tissue  joins 
the  compact  bone  tissue. 

The  signs  and  symptoms  are  the  same  as  in  any  fracture,  with  the 
additional  sign  of  loss  of  contour  of  the  knee-joint.     The  femoral  artery 

may  be  wounded  in  this  fracture,  caus- 
Fjg.  Oy.  ing  a  false  aneurism,  %vhicli  is  of  serious 

import. 

The  displacement  consists  of  flex- 
ion of  the  lower  fragment  on  its  trans- 
verse axis  by  the  action  of  the  (Fig. 
69)  gastrocnemius,  plantaris,  and  pop- 
liteus  muscles,  while  the  rectus  and 
hamstring    muscles   tend    to    i)ull    the 


Fracture  of  ilic  lower  part  of 
tlK*  femur. 


Iuterenudvl<'i>l  h.n 
of  the  fiiiiur. 


lower  fragment  upward,  and  the  aljductor  muscles  draw  the  up]ier 
fragment  inward.  The  lower  fragment  drops  backward  with  tiie 
upper  end  of  the  tibia,  M'hile  th(>  jjatclla  is  thrown  forward.  This 
causes   the   lower  end  of  the    U])per  fragment    to    rest   upon    the   an- 


560 


FRACTURES. 


tcrior  surface  of  the  lower  fragment.  This  disj)laceinent  can  be  over- 
come in  one  of  two  ways  :  either  by  division  of  the  tendo  Achillis  or  by 
the  use  of  tiie  double  incline  plane.  The  contour  of  the  joint  is  so 
destroyed  by  effusion,  esjjccially  when  the  upper   margin  of  the  upper 


Fio.  71. 


Union  "with  deformity  in  supracondyloid  fracture. 

fragment  has  wounded  the  cul-de-sac  extending  upward  upon  the  front 
of  the  femur,  that  the  diagnosis  is  rendered  extremely  tliliicult  unless  it 
is  iiiade  immediately  after  the  injury,  before  swelling  supervenes.  It 
occasionally  happens  that  the  joint  becomes  involved  by  the  fracture 

Fig.  72. 


^Jt 


II 


-M 


1 


Natlian  R.  Smitli's  anterior  splint. 


assuming  a  T-shape  (Fig.  70)  and  thus  extending  into  the  joint  through 
the  intercondyloid  notch. 

The  treatment  of  supracondyloid  fracture,  as  well  as  of  epiphyseal 
separation,  is  conducted  upon  one  of  two  principles  :  either  by  relaxing 
by  natural  means  the  hamstring  muscles  by  the  use  of  a  double-inclined 


SPECIAL  FRACTURES. 


5C1 


])lano,  or  by  artificial  means,  by  division  of  tlie  tendo  Achillis,  which 
secures  physiological  rest  to  the  limb  by  causing  a  temporary  jiarah'sis 
of  the  muscles,  and  thus  preventing  them  from  contracting  and  drawing 
down  the  lower  fragment.  Extension  should  never  be  employed  in  the 
straight  jiosition,  since  tliis  has  a  tendency  to  iutcnsifv  (Fig.  71)  the  dis- 
placeuKnit  and  cause  permanent  ankylosis  in  the  knee-joint.  The  leg 
and  thigh  can  be  placed  in  a  wire  cuirass,  which  is  bent  to  represent  a 
doul)le-inclined  plane,  or  Nathan  Smith's  anterior  splint  (Fig.  72)  can  be 
used,  or  jtlaster  of  Paris  can  be  a[)plied  witli  tlie  knee-joint  sliglitlv  Hexed. 
In  case  tiie  fracture  is  compound,  the  wound  must  be  made  thorougiily 
aseptic,  and  free  drainage  of  the  knee-joint,  with  complete  immobiliza- 
tion, must  be  employed. 

Internal  comlt/loid  fracture  (Fig.  73)  is  produced  by  direct  violence 
through  a  fall  upon  the  bent  knee,  or  by  a  blow  upon  the  condyle,  or 
by  a  severe  lateral  wrench.  Tlie  accident  may  be 
serious  on  account  of  the  proximity  of  the  knee- 
joint  to  the  fracture. 

The  signs  and  symptoms  are  the  same  as  are 
found  in  ordinary  fractures,  such  as  localized  pain, 
ecchymosis,  crej^itus,  and  mobility  of  fragments. 
The  length  of  tlie  limb  is  not  altered,  but  the  nor- 
mal contour  of  the  j'»int  is  destroyed. 

The  treatment  consists  in  jtlaciug  the  entire 
limb  in  the  straight  position  and  applying  some 
evaporating  lotion  over  the  knee-joint  for  a  few 
days,  so  as  to  raodif}'  the  inflauimatory  reaction. 
The  fragment  must  then  be  adjusted  in  its  proper 
])lace  aud  held  in  tiitii  by  compresses.  Flexion  of 
tlie  knee  has  a  tendency  to  displace  the  fragment 
upward.  Ankylosis  is  apt  to  follow  unless  the 
joint  is  subjected  to  gentle  passive  motion  at  the 
end  of  three  weeks.  The  important  clinical  fact 
must  not  be  overlooked  that  the  fragment  may  foil  to  unite,  and  sup- 
puration of  the  knee-joint  has  liecn  observed  in  a  few  cases.  Such  a 
complication  calls  for  the  practice  of  bold  antiseptic  surgery.  Aspira- 
tion of  the  joint  in  this  fracture  is  unwise,  since  it  might  lead  to  serious 
joint-complication. 

External  condyloid  fracture  is  caused  by  a  blow  or  a  fall  upon  the 
condyle  when  the  knee  is  flexed,  and,  like  fracture  of  the  internal  con- 
dyle, may  be  serious  on  account  of  its  close  proximity  to   tlic   knee- 

joi'^it- 

The  signs  and  symptoms  are  the  same  as  in  internal  condyloid 
fracture,  and  tlie  treatment  mentioned  for  one  is  applicable  to  the 
other. 

Fractures  of  the  tthaff  of  the  femur  usually  occur  about  the  centre  of 
the  bone.  Tliey  are  generally  oblique,  with  the  line  of  fracture  in  the 
antero-posterior  direction.  Tliey  are  (caused  liy  direct  or  indirect  violence 
or  by  muscular  action.  Direct  violence  causes  fractures  in  the  lower 
third  ;  direct  and  indirect  violence,  as  well  as  muscular  action,  may 
cause  fractures  in  the  middle  third  ;  while  fractures  in  the  u})per  third 
of  the  bone  are  generally  the  result  of  indirect  violence.     Fractures  of 

Vol.  I.— 36 


f  the  internal 
if  the  femur. 


562 


FRACTURES. 


tlu'  tlii<i;li  in  its  lower  tliird  by  direct  violence  may  be  associated  with 
injury  to  the  femoral  ai'tery  and  vein,  which  lie  in  close  ])roximity  to- 
the  ])Osterior  surface  of  the  bone. 

The  displacement  in  fracture  of  the  femur  is  influenced  somewhat 
by  the  position  of  the  fracture.  For  general  purposes  it  may  be  stated 
that  the  lower  fragment  is  drawn  upward  and  to  the  inner  or  outer  side 
of  the  upper  fragment,  and  is  rotated  outward  (Fig.  74).    This  displ 

Fig.  74. 


lace- 


DisiilaeeuK'Ut  in  fractures  of  shaft  of  femur. 


ment  is  due  to  the  action  of  the  vastus  externus,  vastus  internus  crureus, 
adductor  magnus,  and  adductor  longus  mnsi'les.  The  ujipcr  fragment  is 
flexed  by  the  action  of  the  psoas  and  iliacus  muscles,  and  abducted 
(Fig.  75)  by  the  external  rotators  of  the  thigh.     It  occasionally  happens 


Fig.  75. 


Displ.^comcnt  on  account  of  action  of  psoas  and  iliacus  muscles  and  external  rotators. 


(if  this  member  is  pro- 
impacted  or  else  to  the 


that  instead  of  evcrsion  of  the  foot  inversion 
duced,  due  either  to  the  fact  that  the  fracture  i 
action  of  the  pectineus  and  adductor  brevis. 

The  signs  and  symptoms  of  fracture  of  the  shaft  of  the  femur 
consist  of  shortening  of  the  limb  to  the  extent  of  from  one  to  tliree 
inches,  swelling  at  the  seat  of  fracture,  absolute  inability  to  raise  or 
rotate  the  limb,  eccliymosis,  crepitus,  localized  tenderness  and  pain, 
slight  flexion  and  abduction  of  tiie  upper  fragment,  and,  finally,  unnatural 
mobility.  Synovitis  of  the  knee-joint  often  occurs  in  fractures  of  the 
shaft,  and  has  been  variously  ascribed  to  extravasation  of  blood  into  the 
joint,  or  to  a  concomitant  sprain,  or  to  a  disturbance  of  the  venous 
circulatitin. 

The  prognosis  in  fracture  of  the  shaft  varies  according  to  circum- 


SPECIAL  FRACTURES. 


563 


stances.  The  injuiy  in  any  case  is  more  or  less  serious,  since  it  con- 
fines the  patient  to  bed  for  many  weeks,  compels  him  to  rely  upon 
crutches  for  some  time,  and  finally  may  cause  permanent  lameness  from 
shortening.  In  compound  fracture  the  j)r(igii(>sis  is  exceedingly  grave, 
owing  to  the  shock  from  wliich  the  patient  sutlers.  The  author  has  seen 
death  result  in  conseipience  of  shock  incident  to  simple  fracture,  but,  on 
the  other  hand,  has  treated  several  cases  of  double  compound  fracture  of 
both  thighs  in  which  but  little  shock  was  present  and  the  patients  made 
excellent  recoveries.  If  the  fracture  is  complicated  with  an  injury  to 
the  femoral  vessels  or  a  laceration  of  the  main  nerve-trunk,  the  progno- 
sis is  most  serious,  since  gangrene  may  occur. 

The  treatment  of  Iracture  of  the  shait  of  the  femur  is  somewhat 
complex,  on  account  of  the  many  different  varieties  of  fracture  which 
present  themselves,  as  well  as  owing  to  the  multifarious  methods  still 
in  vogue.  The  indications  are  to  overcome  shortening,  to  control 
muscular  pain  and  spasm,  and  to  produce  fixation  of  the  fragments. 

Fi(i.  76. 


Adliesive  plaster  applied  for  extension. 


It  seems  wholly  umiecessary  to  review  the  older  methods  of  treat- 
ment, since  the  recent  ones  are  generally  accepted  as  far  superior  in 
every  respect.      The  first  indication 


VIZ.  to  overcome  shortening — is 


Fig.  77. 


E.xtension  apparatus  fur  Iracture  of  the  tliigh  (modifierl  from  Gurilcn  B\uki. 


met  l)y  the  u.se  of  the  weight  and  pulley  (Fig.  77),  known  as  Buck's 
extension  method.  The  amount  of  weight  required  (k'pends  upon  the  age 
of  the  individual,  the  amount  of  mu.scular  rigidity  to  be  overcome,  and  the 


564 


FRACTURES. 


Fig, 


direction  of  the  fracture.  In  applying  tiie  adhesive  plaster  to  the  limb 
the  strip  slioukl  extend  above  the  knee-jidnt  and 
nearly  iij)  to  the  seat  of  fracture,  since  this  gives 
less  freedom  of  motion  and  takes  the  strain  off  from 
the  knee-joint.  The  amount  of  weight  required  to 
overcome  the  shortening  varies  from  five  to  twenty- 
five  pounds.  The  less  weight  that  is  used,  the  more 
likely  it  is  that  the  ])atient  will  tolerate  the  extension 
for  a  long  time  (Fig.  77).  The  counter-extension 
is  made  by  elevation  of  the  loot  of  the  bed.  Another 
method  of  maintaining  extension  to  overcome  short- 
ening is  by  the  use  of  a  spica  of  plaster-of- Paris  band- 
age applied  while  the  muscles  are  relaxed  during 
anaesthesia.  This  extension  is  maintained  by  the  use 
of  strips  of  perforated  zinc  or  tin  under  tlie  jilaster, 
and  a])plied  according  to  Fluhrer's  method.  Still 
other  methods  are  by  the  vertical  extension  of  the 
thigh  (Fig.  78);  or  by  Liston's  long  sj)lint  with  its 
perineal  band,  consisting  of  a  tubular  bag  filled  with 
wool  or  a  soft  jmkI  made  of  leather  ;  or  by  Owen 
Thomat^'s  hip-s]ilint ;  or  l)y  the  stirrup  of  Brown  or  Cripps ;  or,  finally, 
by  Nathan  K.  Smith's  anterior  sjilint. 

The  next  indication — viz.  to  control  muscular  spasm  and  pain — is 
best  met  by  the  use  of  a  long  sj^lint  to  which  the  thigh  can  be  bandaged, 
and  the  entire  limb  thus  kc])t  in  its  proper  relation  to  the  trunk.  If  the 
nniscvilar  si)asm  and  irritability  are  severe  and  cause  mucli  pain,  tenotomy 
of  the  hamstring  muscles  will  at  once  relieve  this  condition. 

Tiie  last  indication  is  met  l)y  the  use  of  coa])tation  splints,  four  in 
number,  placed  around  the  thigh  over  the  seat  of  fracture.  They  should 
be  two  inches  wide  and  about  eight  inches  long,  well  padded  and  fixed 
to  the  limb  by  strips  of  adhesive  or  rubber  plaster  about  one  inch  in 
width. 

In  case  of  fracture  of  the  thigh  in  children,  employ  either  the  spica  of 


Fracture  of  the  femur 
in  a  child  treated  by 
vertical  extension.  ' 


Fig.  79. 


Hamilton's  splint  for  fracture  of  the  femur  in  children. 


plaster-of-Paris  bandage  with  Fluhrer's  perforated  strips,  or  Hamilton's 
double  splint  (Fig.  79),  consisting  of  two  long  straight  splints  connected 
below  the  foot  by  a  cross-piece,  and  extending  on  both  sides  from  below 


SPECIAL  FRACTURES. 


565 


the  feet  to  the  axillse,  with  tlie  linihs  l):in(l;i<i:e(l  to  tlie  thi<rh.  Cliildren 
with  fracture  of  the  tliigii  euii  he  carrietl  about  in  this  dressing,  and  are 
therefore  not  so  niueh  confined  as  by  the  otlier  nietlKxh 

Fracture  just  below  the  trochanter  is  substantially  a  fracture  of  the 
shaft  of  tlie  bone  in  its  upper  part,  and  special  consideration  is  given 
to  it  only  because  it  jiermits  of  but  one  kind  of  treatment.  The  upper 
fragment  is  tilted  ujiward  and  abducted  by  the  action  of  the  psoas  and 
iliacus,  which  are  inserted  into  the  process,  and  al)ducted  by  the  external 
rotators.  The  lower  fragment  is  abducted  and  drawn  up  Ity  the  extensor 
muscles. 

The  treatment  consists  in  placing  the  limb  in  an  apparatus  which  will 
cause  the  axis  of  the  lower  fragment  to  conform  to  that  of  the  upper  or 
small  fragment.  This  can  be  accomplished  only  by  the  use  of  a  double- 
inclined  plane,  and  the  shortening  must  l)e  overcome  by  Buck's  exten- 
sion, wliicli  is  iqiplicd  to  the  lower  fragment.  The  upi'ight  over  or 
through  which  the  j)ullcy  runs  must  be  placed  several  feet  above  the 
level  of  the  foot  of  the  bed,  so  that  the  traction  is  in  the  line  of  the 
long  axis  of  the  femur  while  resting  upon  the  upward  plane  of  a  Mc- 
Intyre  splint.  This  method  must  be  observed  in  order  to  prevent 
union  of  the  fragments  with  angular  deformity. 

Fracture  of  the  trochanter  major  is  caused  by  a  blow  direct  upon  the 
process  or  by  a  fall  upon  it.  The  fragment  is  displaced  by  the  action  of 
the  external  rotator  muscles,  which  draw  the  fragment  upward  and  Ijack- 
ward. 

The  signs  and  symptoms  of  this  fracture  arc  those  found  in  ordinary 

Fid.  80. 


Fracture  of  trnchantir  major. 


fractures,  with  the  exception  that,  while  there  is  no  shortening  in  the 
limb  itself,  the  line  in  Bryant's  triangle  is  shortened  the  same  as  in  frac- 
ture of  the  neck  of  the  thigh-bone  (Fig.  80). 

The  treatment  consists  in  abductiny  the  limb  of  the  affected  side  and 


566 


FRACTURES. 


placing  a  compress  above  and  heliind  the  frnjiment.     The  compress  is  to 
l)e  kci)t  in  place  by  strii)s  of  rnblier  (jr  adliesive  ])lastcr. 

J'J.rfra-cci psu/ar  frdctnre  of  the  ccrrixfciaoris  jrencrally  occurs  as  a  result 
of  direct  violeuce,  either  by  a  blow  upon  the  trochanter  major  or  else  by 
a  fall  upon  the  hip.  The  \veight  of  the  body  in  falling  comes  directly 
upon  the  neck  of  the  thigh-bone,  and,  since  the  neck  is  attached  ol)li<|Uely 
to  the  shaft,  the  force  of  the  fail  or  blow  is  transmitted  to  it  and  a  frac- 
ture follows.  If  the  force  wiiich  produces  the  fracture  continues  to  act, 
the  compact  tissue  of  the  neck  of  the  bone  is  driven  firndy  into  the  loose 
cancellated  tissue  of  the  trochanter,  and  an  impacted  fracture  is  ])ro- 
dueed.  The  direction  of  the  fracture  in  front  is  along  the  insertion  of  the 
capsular  ligament,  which  is  the  anterior  intertrochanteric  line,  and  behind 
the  fracture  is  outside  of  tlie  cajwule,  but  just  internal  to  tlie  ])osterior 
intertrochanteric  line  (Fig.  81).     In  many  eases  the  line  of  fracture  is 


Fig.  81. 


Intra-  and  exlra-capsular  fracture  of  neck  ot  femur. 

found  to  be  partly  within  and  partly  without  the  capsule  of  the  joint, 
and  in  some  eases  there  are  several  distinct  fragments — viz.  one  composed 
of  the  head  and  neck  of  the  bone,  another  of  tlie  trochanter,  while  still 
another  may  consist  of  a  part  of  the  shaft  of  the  bone. 

Before  entering  ujjon  a  study  of  the  signs  and  symptoms  of  extra- 
capsular fracture  of  the  neck  of  the  thigh-bone  it  is  necessary  to  exjilain 
Bryant's  triangle  and  Nelaton's  line,  with  a  view  to  a  complete  under- 
standing of  the  nature  of  this  injury.     This  knowledge  will  be  useful  in 


SPECIAL  FRACTURES. 


567 


considering  all  injuries  about  the  hip-joint,  and  therefore  will  be  intro- 
duced in  connection  with  a  study  of  this  special  variety  of  fracture. 

Bryanfs  ilio-fenwral  triangle  is  formed  by  drawing  a  line  from  the 
anterior  superior  spinous  process  of  the  ilium  to  the  trochanter  major 
as  line  a,  b,  and  another  line  perpendicularly  from  the  anterior  superior 
spinous  process  to  a  point  on  a  level  with  the  termination  of  line  A,  B, 

Fig.  82. 


Bryant's  ilio-feinoral  triangle,  for  diagnosis  of  fracture  of  tlie  necli  of  tlie  fonmr. 

as  in  line  A,  c.  A  third  line,  e,  B,  joining  the.se  two  points  of  termi- 
nation in  a  normal  joint  measures  about  two  and  a  half  inches  (Fig.  82). 
In  case  of  fracture  the  base  line  is  less  than  two  and  a  half  inches,  or 
less  than  a  corresponding  line  in  a  triangle  upon  the  opposite  hip. 

Nelaton's  line  is  drawn  from  the  anterior  superior  spinous  process  of 
the  ilium  to  the  tuberosity  of  the  ischium,  and  should  in  the  normal 
joint  just  toucii  tlie  ujiiier  border  of  tlic  trochanter  major.  In  case  of 
fracture  or  dorsal  di.slocation  of  the  hip-joint  the  upper  border  of  the 
troclianter  major  is  above  Nelaton's  line. 

The  signs  and  S3nnptoms  of  extra-ca{)sular  fracture  of  the  neck  of 
the  thigh-bone  consist  of  crepitus,  elicited  by  placing  the  palm  of  the 
hand  over  the  trochanter  major  during  forced  rotation  of  the  thigh, 
superficial  pain,  tenderness  and  swelling,  shortening  of  the  limb  to  the 
extent  of  about  two  and  a  half  inches,  rotation  outward  of  the  thigh,  and 
complete  eversion  of  the  foot,  with  contusion  and  ecchymosis  over  the 
joint.  The  arc  of  the  circle  transcribed  by  the  trochanter  major  is  less 
than  it  is  over  the  sound  joint,  since  the  trochanter  major  moves  upon 
a  shorter  radius.  These  signs,  together  with  the  history  that  the  patient 
has  received  a  severe  fall  directly  upon  the  trochanter  major  or  a  blow 
transversely  ap])lie(l,  and  is,  as  a  rule,  under  fifty  years  of  age,  indicate 
this  form  of  fractiu-e.  In  case  the  fracture  is  impacted  many  of  the 
signs  mentioned  are  not  present.  The  trochanter  is  often  broadened  or 
enlarged,  while  its  relation  to  the  base  line  in  Bryant's  triangle  is  altered. 
Another  sign  of  extra-capsular  fracture  of  the  thigh-bone  has  been  pointed 
out  by  Allis — viz.  the  relaxation  of  the  fascia  lata. 

The  prognosis  is  serious  as  regards  life,  since  in  some  eases  pneu- 
monia, Ijronchitis,  fat-embolism,  pulmonary  thrombosis,  inanition,  bed- 
sores, or  traumatic  delirium  destroys  the  life  of  the  patient.  In  other 
cases  the  prognosis  is  unfax'orable  in  regard  to  the  function  of  the  limb, 
which  is  more  or  less  impaired.  Asa  rule,  a  person  over  seventy  years 
of  age  with  a  fracture  of  the  neck  of  the  thigh  will  be  jiermanently  a 
crip])le,  and  often  Ix'dridden. 

The  treatment  of  extra-ca])sular  fracture  consists  in  the  application 


5G8 


FRACTURES. 


Fig.  83. 


of  a  plaster-of-Paris  spiea  to  the  liij)  wliile  extension  is  made  during 

ansesthesia.     Tiie  limb  within  tlie  splint  is  prevented   from  retracting 

by  the  use  of  perforated  strips  of  zinc  or  tin  adjusted  to  the  outer  side 

of  the  s]ilint  between  the  layers  of  plaster. 

Another  method  of  treatment  is  by  Liston's  long  splint  in  conjunction 

with  the  weight-and-pnlley  apj)aratus,  as  described  in  connection  with 

fractures  of  the  shaft  of  the  fenuir. 

This  fracture  usually   unites  firmly,  and   the   result  is  satisflictory 

except  in  old  persons,  but  occasionally  there  is  some  slight  rigidity  in 

the  hip-joint. 

The  prognosis  as  regards  recovery  and  usefulness  of  the  limb  is  in 

marked   contrast  to  the   result  usually   obtained   in   the   intra-capsular 

fracture. 

Intra-capsular  fracture  of  the  neck  of  the  tliif/h-bone  is  of  frequent 

occurrence,  and  is  usually  seen   in   elderly  people,  chiefly   in    women. 

The    frequency  of   this    fracture    in    the    aged    is    ascribed    to    certain 

senile   changes   which  take    place    in  the   bone    itself  or  in  the  angle 

which  the  neck  of  the  bone  assumes  to  the  shaft  late  in   life.     In  tlie 

young  and  during  adult  life  this  angle  is 
oblique,  while  in  the  aged  it  becomes  almost  a 
right  angle,  and  the  head  of  the  bone  is  sunk 
below  the  level  of  the  top  of  the  trochanter. 
Besides  the  changes  in  regard  to  the  angle 
at  which  the  neck  is  jilaced  to  the  shaft  the 
cancellated  tissue  undergoes  a  senile  atrophy 
owing  to  fiitty  degeneration,  and  the  com- 
pact bony  tissue  becomes  thin  and  fragile. 
This  fracture  is  generally  caused  by  some 
slight  injury,  such  as  trij)]iing  the  toe  over 
the  threshold  of  the  door,  or  slipping  upon 
a  rug  or  o\'er  a  curbstone,  or  even  turning 
suddenly  over  in  bed.  The  seat  of  the  frac- 
ture, as  its  name  implies,  is  within  the  cap- 
sule of  the  joint  (Fig.  83).  This  fracture  is 
occasionally  impacted,  and  in  this  case  the 

intra-eapsuiar  fracture  ofthe  neck  of  neck  of  the  bone  is  driven  into  the  cancel- 

the  femur.  11.  n     ^         ^  t        ,'     ^         ^  T 

lated  tissue  oi  the  head  oi  the  bone.  Im- 
paction, however,  is  rare  as  compared  with  the  same  condition  as  found 
in  the  extra-capsular  fracture. 

The  signs  and  symptoms  of  intra-capsular  fracture  of  the  neck  of 
the  thigh-bone  consist  of  crepitus  and  pain  which  are  deep-seated,  and 
shortening  ofthe  limb  to  the  extent  of  an  inch  at  first,  and  subsequently 
more  on  accoiuit  of  atrophy  and  absorption  of  the  neck  ;  shortening  of 
the  base  line  in  Bryant's  triangle ;  the  projection  of  the  trochanter  major 
above  Nelaton's  line,  thus  pnjducing  a  closer  proximity  to  the  crest  of 
the  ilium ;  alteration  in  the  sliape  of  the  hi]i,  manifested  by  flattening 
of  the  trochanter,  and  in  the  axis  of  the  limb  ;  relaxation  of  the  fascia 
lata,  tensor  vaginae  femoris,  and  gluteus  medius  muscles ;  puckering  of 
the  integument  over  the  ligamentum  patelhe,  due  to  shortening  of  the 
limb  ;  outward  rotation  of  limb  and  eversion  of  foot,  due  to  a  mechanical 
cause,  since  the  centre  of  gravity  is  below  a  line  drawn  from  the  ace- 


SPECIAL  FRACTURES.  569 

tabulum  to  the  heel,  and  tlie  weight  of  the  limb  thus  foils  outward  ;  and 
also  to  a  physiologieiil  cause,  since  the  external  rotators  act  upon  tiie  lower 
fragnicut ;  and  tiie  absence  of  the  ecchymosis  over  tiie  joint  which  is 
seen  in  extra-capsular  fracture.  The  arc  of  the  circle  transcribed  by 
the  trochanter  major  is  greater  than  in  the  extra-capsular  fracture,  but 
less  than  upon  the  opposite  side,  owing  to  a  shorter  radius.  These  signs, 
together  with  the  history  of  a  slight  fall  upon  the  knee  or  foot  in  an 
aged  individual,  especially  a  woman,  make  the  diagnosis  certain.  If 
inversion  of  the  foot  occurs,  it  is  exceptional,  and  is  due  to  impaction 
of  the  fragment'^  or  possii)Iy  to  a  paralysis  of  the  external  rotators; 
whicii  condition  may  be  the  result  of  an  injury  received  at  the  same  time 
as  the  fracture. 

The  treatment  of  intra-cajisular  fracture,  as  a  rule,  is  unsatisfactory, 
since  the  patients,  on  account  of  their  age,  are  usually  in  jxior  physical 
condition,  and  hence  the  reparative  process  is  retarde(l.  The  fracture 
generally  fails  to  unite,  owing  to  tiie  non-approximation  of  the  frag- 
ments, to  the  enfeebled  condition  of  the  patient,  to  a  lack  of  sufficient 
arterial  supply,  and  to  the  presence  of  synovia  between  the  fragments. 

The  surgeon  must  not  mistake  for  an  intra-capsular  fracture  a  dis- 
location of  the  hip,  the  differential  points  of  which  are  ]>resented  at 
length  under  Dislocation.  In  contusion  of  the  hijHJdiut  the  presence 
of  tlie  head  of  the  bone  in  the  acetabulum  and  the  al)sence  of  all  the 
characteristic  signs  belonging  to  fracture  serve  to  render  the  diagnosis 
clear.  A  fracture  within  the  capsule  can  be  diagnosticated  if  the 
head  of  the  bone  is  in  the  acetabulum  and  immediate  shortening  has 
occurred,  for  under  these  circumstances,  unless  the  fragments  are 
impacted,  crepitus,  eversion  of  the  foot,  shortening  of  the  limb,  and 
loss  of  function  are  always  present,  and  make  the  diagnosis  certain 
and  the  s]>ecial  line  of  treatment  perfectly  clear.  The  surgeon  should 
make  a  judicious  choice  as  to  the  special  method  by  which  a  patient 
with  this  injury  is  to  be  treated.  If  the  patient  is  in  good  phys- 
ical condition,  not  too  aged,  and  not  of  a  nervous  temperament,  an 
attempt  shduhl  be  made  to  secure  union  in  the  fracture.  To  this  end 
a  long  Liston  splint  should  be  adjusted,  and  a  weight  and  pulley 
attached  to  the  foot  in  order  to  steady  the  leg  and  overcome  a  certain 
amount  of  shortening.  During  the  period  of  repair  attention  must  l)e 
directed  to  the  avoidance  of  bed-sores  and  to  the  maintenance  of  the 
general  health,  upon  which  so  much  depends  in  the  management  of 
these  cases.  All  parts  of  the  hndy  must  be  kept  strictly  and  absolutely 
clean,  and  the  patient  sujtported  by  the  most  nutritious  diet,  with 
judicious  stinndation  if  necessary.  Anodynes  may  be  indicated  in 
case  of  loss  of  sleep  or  to  contnd  pain,  while  remedies  to  aid  digestion 
and  tonics  containing  the  hypophosphites  of  lime  and  soda  can  be 
emjdoyed  M'ith  advantage. 

In  some  cases  this  fracture  can  lie  treated  by  a  plaster-of-Paris  spica, 
wliich  is  a  form  of  dressing  which  does  not  confine  the  patient  to  the 
bed,  but  permits  him  or  her  to  rest  on  a  lounge  or  even  to  be  moved 
around  in  a  roller  chair.  Great  care  nuist  be  exercised  lest  the  splint 
produce  excoriation  of  the  skin  in  elderly  people,  since  this  will  lead  to 
the  formation  of  bed-sores,  a  most  unfortunate,  painful,  and  often  fatal 
complication.     In  ntlier  cases  patients  arc  intolerant  of  the  use  of  any 


570 


FRACTURES. 


splint  or  dressing,  and  seem  nidre  (Mimfortabie  witlioiit  any  fixed  appa- 
ratus, except  ])erliaps  sand-hags,  wliieii  serve  to  prevent  rotation  of 
the  linil).  A  liglit  weigiit  applied  to  the  foot  will  sometimes  help  to 
keep  the  fracture  quiet  and  atlbrd  the  patient  relief. 

It  has  been  suggested  to  unite  the  broken  surfaces  by  ivory  pegs,  but 
this  operation  is  one  of  a  serious  nature  and  of  doubtful  expediency  in 
tiie  ag<>d.  Tile  best  result  that  can  l)e  attained  is  often  very  unsatisfactory, 
and  in  many  cases  the  ])atieuts  succumb  from  the  effects  of  this  injury. 
\i  tile  fracture  is  imjiacted  and  the  patient  is  in  good  physical  condition, 
occasionally  an  excellent  result  follows. 

Fractures  of  the  pelvis  form  considerably  less  than  1  per  cent, 
of  the  fractures,  and  derive  their  chief  importance  from  accomjianying 
injury  to  the  pelvic  viscera.  In  this  resj)ect  fractures  of  tiie  ])clvis 
resemble  fractures  of  the  skull,  in  which  tiie  gravity  is  influenced  not  so 
mucli  l)y  tlie  extent  of  the  fracture  as  liy  the  damage  sustained  by  the 
contents  of  the  skull. 

Fractures  of  the  pelvis  (Fig.  84)  may  be  situated  along  the  crest  of 


Fiii.  84. 


Fracture  of  the  pelvis. 

the  ilium,  in  the  pelvic  basin,  or  in  the  acetabulum.  Fractures  involv- 
ing the  crest  of  the  ilium  are  usually  produced  Iw  direct  violence,  as  by 
the  pa.ssage  of  a  wagou-wheel  across  the  pelvis,  or  Ijy  a  heavy  weight 
falling  upon  the  patient,  or  by  crushing  while  in  the  act  of  coupling 
cars. 

The  signs  of  this  fracture  are  pain,  crepitus,  ecchymosis,  and  ina- 
bility to  move  the  muscles  attached  to  the  ilium. 


SPECIAL  FRACTURES.  571 

The  treatment  consists  in  keeping  tlie  patient  quiet  in  bed  and  the 
application  of  a  long  Liston  splint  reaching  from  the  axilla  to  the  ft)ot. 
The  fragments  themselves  can  be  adjusted  and  held  in  .sitii  by  the 
aj)plication  of  pads  or  compresses,  which  are  retained  by  adhesive 
plaster,  or  liy  a  Bavarian  plaster-of-Paris  splint  applied  so  as  to  tit  all 
the  salient  points  of  the  pelvis,  or  by  a  gutta-pereha  or  felt  splint 
applied  after  first  moulding  it  to  the  sound  side. 

Frnrfure  offhrpdvicbaniii  is  usually  situated  in  the  jiubic  bone.  The 
direction  of  the  fracture  is  through  tlie  ujiper  ranuis  upon  the  inner  side  of 
tlie  jM'ctineal  eminence,  and  tlien  through  the  lower  ramus  near  the  point 
at  wliich  tlie  pubis  joins  the  iscliium. 

The  displacement  is  very  slight,  as  a  rule.  Palpation  of  the  outline 
of  the  pelvis  will  often  reveal  the  amount  of  displacement. 

The  prognosis  in  this  fracture  is  dependent  upon  the  existence  of 
visceral  injury.  In  the  absence  of  any  injury  to  the  viscera  suppuration 
in  the  loose  connective  tissue  in  front  of  the  bladder  is  a  complication 
that  often  ensues. 

The  signs  and  ssrmptoms  of  fracture  of  the  pelvic  basin  consist  of 
localized  pain,  greatly  increased  upon  pressure,  inability  to  elevate  the 
limb,  crepitus,  ecchyniosis,  and  displacement.  In  these  cases  there  is 
usually  injury  to  the  pelvic  viscera.  The  urethra  may  be  lacerated  as 
it  passes  under  tlie  arch  of  the  }>ubis,  either  by  a  sharp  fragment  of 
bone  or  by  separation  of  the  symphysis.  A  catheter,  thoroughly  cleansed 
and  boiled,  should  be  introduced  into  the  urethra  down  to  the  seat  of 
the  laceration,  and  then  an  external  perineal  urethrotomy  performed.  It 
may  not  be  necessary  to  o]ien  into  the  bladder,  but  a  sound  must  be  passed 
ut  stated  intervals  in  the  future  to  avoid  the  formation  of  traumatic 
•strictures.  A  catheter  should  be  immediately  introduced  into  the  bladder 
for  the  purpose  of  ascertaining  whether  a  rupture  of  this  viscus  has  oc- 
curred. If  clear  urine  escapes,  it  is  presumptive  evidence  that  the  blad- 
der is  uninjured.  This,  however,  is  not  an  absolute  proof,  and  further 
investigation  should  be  made.  Eight  ounces  of  Thiersch's  antiseptic 
fluid  should  be  injected  into  the  bladder,  and  if  this  exact  amount  is 
immediately  witlidrawn  ruptui-e  of  the  bladder  is  in  all  probability  not 
present.  Even  this  procedure  is  not  an  infallilile  test,  since  a  rent  in 
tlie  bladder-wall  has  been  found  of  a  valve-like  character,  so  that  disten- 
tion of  the  bladder  closes  the  opening  and  no  fluid  escapes  into  the  peri- 
toneal cavity,  although  a  rupture  of  the  bladder-wall  exists.  If  after  a 
few  hours  folhjwing  this  examination  Inematuria  occurs,  some  doubt  may 
arise  as  to  tlie  accuracy  of  the  diagnosis.  The  question  then  to  decide 
is  whether  the  blood  found  in  tlie  urine  has  its  origin  from  the  bladder, 
or  wlicthcr  the  liiood  is  from  tlie  kidney  as  a  result  of  laceration  of  tliis 
organ.  The  presence.of  hiematuria  occurring  some  hours  after  a  pelvic 
fracture,  the  fact  that  the  blood  is  uniformly  mixed  with  the  urine,  and 
not  found  in  clots,  as  is  usual  in  hemoi'rhage  from  the  bladder,  and  the 
evidence  derived  from  the  microscopical  examination  of  the  bloody  urine, 
will  make  aljsolutely  certain  the  diagnosis  as  to  the  source  of  the  hemor- 
rhage and  the  injury  of  the  viscera. 

Hsematuria,  due  to  an  injury  to  the  bladder-wall  or  to  the  kidney- 
substance,  must  not  be  mistaken  for  a  hemorrhage  from  the  urethra 
dependent  upon   a   laceration  of  this  canal  at  the  triangular  ligament. 


572 


FRACTURES. 


The  passage  of  a  sound  will  ciiMbk'  the  surgeon  to  arrive  at  a  conclusion 
as  to  this  possible  source  oi"  Jieniorrhagc.  A  digital  examination  of  the 
rectum  should  be  made  to  ascertain  if  the  pelvic  vessels  are  torn  or  if 
the  bowel  itself  has  sustained  any  injury.  If  the  patient  is  a  female, 
it  may  be  necessary  to  make  a  vaginal  examination  in  order  to  be  sure 
that  none  of  tlie  pelvic  organs  are  injured  by  tiie  fracture.  If  the  exam- 
ination reveals  the  fact  that  the  bladder  is  injured,  a  lajjarotomv  should 
be  immediately  performed,  as  tirst  descril)ed  in  detail  l)v  Sir  Wm.  Mac- 
Cormac,  the  peritoneal  cavity  should  be  irrigated,  the  wound  in  the  blad- 
der-wall closed,  and  drainage  during  repair  maintained,  either  by  a  tube 
brought  out  at  the  lower  angle  of  the  abdominal  \\onnd  or  else  by  a  soft 
catheter  introduced  into  the  urethra  and  kept  ase])tically  clean. 

The  management  of  the  fractur(>  itself  is  conducted  uj)on  the  same 
principle  as  that  of  fracture  of  the  ilium.  The  long  Liston  splint  should 
be  applied  to  both  limbs,  slight  flexion  of  the  knees  with  modi'rate 
extension  by  the  double  weight  and  jiulley  should  be  employed,  and  the 
adaptation  of  some  form  of  pliable  splint  or  bandage,  such  as  felt,  leather, 
or  plaster  of  Paris,  should  be  made  in  order  to  kec])  the  fragments  at  rest. 
Fractures  of  the  acetabulum  may  occur  sinuiltaneously  witii  a  disloca- 
tion of  the  hip,  but  this  special  variety  of 
fracture  is  exceedingly  rare.  The  frac- 
ture, when  independent  of  a  dislocation, 
may  involve  only  the  rim  of  the  acetab- 
ulum, most  fre(piently  the  posterior  lip, 
or  it  may  involve  the  floor  of  the  acetab- 
ular cavity.  It  sometimes  haj)pcns  that 
the  head  of  the  femur  is  driven  through 
the  floor  of  the  joint-socket  into  the  pel- 
vic cavity  (Fig.  85). 

The  signs  and  symptoms  of  fracture 
of  the  acetabulum  consist  of  pain,  ren- 
dered acute  by  pressure  over  the  trochan- 
ter major  ;  an  acute  synovitis  of  the  hip- 
joint,  with  all  the  manifestations  of  effu- 
sion within  the  capsule  ;  the  presence  of 
crepitus  in  some  cases  ;  or  the  evidences 
of  impaction  of  the  head  of  the  bone  in 
Comminuted  fracture  of  the  acetabulum.   Other   cases.     If  the   head  of  the  bone 

has  been  forcibly  driven  through  the 
floor  of  the  joint-cavity  into  the  pelvic  cavity,  there  are  also  present 
the  signs  of  injury  of  the  pelvic  viscera. 

The  complications  are  to  be  treated  according  to  the  rules  just  laid 
down  in  discussing  this  question  in  connection  with  fractures  of  the 
pelvic  basin.  The  fracture  itself  can  be  best  treated  by  the  same 
method  as  intra-capsular  fracture  of  the  neck  of  the  thigh-bone  or  a 
fracture  of  the  pelvic  basin. 

Fracture  of  the  iiyoid  boxe  seldom  occurs,  owing  to  the  mobility 
of  the  bone  and  the  protection  which  is  aftorded  to  it  by  the  inferior  maxil- 
lary bone.  These  fractures  are  usually  caused  by  a  direct  blow  upon  the 
neck  or  by  some  one  throttling  the  patient  in  an  attempt  at  violent 
assault,  or  by  a  fall  from  a  height,  or  during  the  act  of  judicial  or 


SPECIAL  FRACTURES. 


573 


suicidal  lianging.  The  junction  of  the  body  of  the  bone  with  the 
greater  cornu  is  the  usual  seat  of  the  fracture.  There  are  some  cases 
recorded  where  a  fracture  of  this  bone  has  occurred  as  a  result  of  mus- 
cular action. 

The  signs  and  ssnnptoms  are  those  wliich  are  found  in  common 
witli  ordinary  fractures  of  other  bones.  The  patient  usually  hears  a 
sudden  sna[),  and  at  the  same  time  experiences,  with  a  sense  of  sutfoca- 
tion,  acute  pain.  There  is  usually  a  slight  hemorrhage  from  the  mouth, 
produced  by  a  laceration  of  the  mucous  membrane  of  the  pharynx. 
Movement  of  the  head  is  attended  witli  severe  pain,  and  tlie  j)atient  is 
unal)le  to  ])rotrude  the  tongue.  The  voice  is  hoarse,  and  articulation  as 
well  as  deglutition  becomes  very  painful.  Dyspncea,  expectoration  of 
bloody  mucus,  and  irregularity  of  the  pulse  are  symptoms  often 
observed. 

The  prognosis  is  favorable  if  the  fracture  of  the  bone  is  not  asso- 
ciated with  injury  to  the  larynx,  but  when  this  complication  is  present 
nearly  50  per  cent,  of  the  eases  are  fatal.  The  danger  of  axlema 
glottidis  must  not  be  lost  sight  of,  since  this  condition  is  likely  at  any 
time  to  arise. 

Treatment. — An  attempt  should  be  made  at  once  to  reduce  the  frag- 
ments l)v  placing  the  left  index  finger  of  the  surgeon  in  the  patient's 
moutli,  and  witli  the  thumb  and  index  finger  of  the  right  liand  making 
external  jiressure  until  the  fragments  arc  brought  into  apposition.  If  tiic 
parts  art'  not  easily  bi-ouglit  together,  it  may  he  necessary  to  administer 
an  auiestiietic,  during  wliich  the  surgeon  must  guard  against  the  danger 
of  the  patient  swallowing  the  tongue.  The  patient's  head  should  now  be 
flexed  forward,  and  lield  in  this  position  by  some  retentive  apjiaratus 
which  extends  from  liotli  sides  of  the  head  to  the  slioulders.  A  collar 
consisting  of  leather  or  felt  or  jilaster  of  Paris,  like  the  Bavarian  splint, 
can  he  jtlaccd  around  the  neclv  and  ap])licd  to 
it  wliile  wet,  so  that  the  collar  can  adapt  itself  to 
the  salient  points  of  the  neck.  The  oesophageal 
tube  must  be  used  to  feed  the  patient,  who  for 
ten  days  at  least  must  not  be  allowed  to  talk. 

(Edema  f//ofii(lin  (Fig.  8ti)  is  a  coni]ilication 
that  may  arise  at  any  moment,  and  if  iiiflani- 
niation  or  dyspncea  is  present  a  prophylactic 
tracheotomy  should  be  immediately  performed. 
If  the  soft  parts  within  the  mouth  are  lacerated 
and  there  is  much  ecchymosis  externally,  it  is 
best  to  perform  a  prophylactic  tracheotoiiiy,  as 
it  is  unsafe  to  <lelay  this  operation  until  cedcma 
glottidis  is  established,  as  in  these  cases  death 
occurs  instantly  and  without  any  warning. 

Fracture  of  the  rib  occurs  in  the  proportion  of  about  18  per 
cent,  of  all  fractures.  This  fi-acture  is  frequent  in  adults,  but  very 
itifrc(|uent  in  children,  owing  to  the  elasticity  of  the  cartilage  connect- 
ing the  rib  to  the  sternum  and  the  strength  of  the  ligament  connecting 
the  rib  to  the  vcrtelira.  The  elasticity  is  so  great  in  children  that  the 
arch  yields  without  breaking  upon  the  application  of  violent  jiressure. 
A  carriage  has  been  known  to  pass  over  the  chest  of  a  child,  and  on 


Fio.  8G. 


CEdema  of  the  glottis. 


574  FRACTURES. 

account  of  the  elasticity  no  fracture  occurred.  In  tlie  aged  this  elasticity 
is  lost,  owing  to  a  certain  anioiuit  of  ossification  of  the  cartilage  and  to 
senile  atrojthy  of  the  rib  itself,  wiiieh  causes  it  to  be  fragile  and  inelastic. 
'J^he  ril)s  of  tlie  insiuie  are  said  to  be  very  brittle,  owing  to  the  great  pro- 
portion of  earthy  to  organic  matter. 

The  ribs  most  frequently  fractured  are  from  the  fourth  to  the  eighth, 
the  seventh  rib  being  the  one  most  frequently  found  to  be  the  seat  of 
fracture.  The  uj)per  ribs  are  ])roteeted  from  injury  by  the  pectoral 
muscles  and  the  clavicle,  wliile  the  lower  or  lidse  rilts  yield  on  account 
of  their  great  mobility.  Indeed,  fractures  of  the  first  and  last  ribs  are 
almost  unknown.  The  fracture  is  usually  at  or  near  the  angle  of  the 
rib  and  about  four  inches  from  its  attachment  to  the  vertebral  column, 
since  at  this  point  the  two  forces,  the  blow  and  the  recoil,  meet.  Occa- 
sionally, however,  a  fracture  is  found  near  the  junction  of  the  costal 
cartilage. 

The  cause  of  fracture  of  the  rib  may  be  direct  violence,  as  when 
the  rib  is  struck  and  the  fragments  are  driven  inward.  In  this  variety 
of  fracture  the  pleura  and  lung  may  be  injured.  The  fracture  may  also 
be  caused  by  indirect  violence,  as  when  the  chest  is  suddenly  compressed 
and  the.  fragments  are  driven  outward  and  snap.  Finally,  fracture  of  the 
rib  has  been  caused  by  nniscular  action  during  the  act  of  ])artnrition. 
Malgaigne  has  i-eported  a  case  of  fracture  due  to  the  impulse  of  the  heart. 

Fractures  of  the  ribs  are  simple,  or  compound  as  in  gunshot  or 
.stab  wound,  or  complicated,  as  when  the  diaphragm,  ])leura,  lung,  or 
the  peritoneum  is  M'ounded.  A  complicated  fracture  of  tlie  rib  has 
been  observed  in  a  few  cases  where  the  fragment  injured  the  heart,  or 
where  the  chest-cavity  has  been  compressed  so  as  to  cause  an  injury  of 
the  heart  without  an  accompanying  wound  of  the  ])ericanlium.  A  com- 
plicated fracture  of  the  rib  has  been  ol)served  by  the  writer  in  which 
the  patient  fractured  one  of  the  floating  ribs  in  an  attempt  to  get  out  of 
a  berth  while  on  shipboard.  The  patient  was  thrown  violently  against 
the  side  of  the  berth  and  struck  the  lower  rib,  which  suddenly  fractured, 
and  at  the  same  time  womidcd  the  peritoneum,  so  tliat  a  traumatic  peri- 
tonitis was  developed  ;  from  which  attack,  however,  the  patient  made  an 
excellent  recovery. 

The  signs  and  symptoms  of  fracture  of  the  rib  may  be  classified 
as  local  and  general.  Among  the  local  signs  are  sharp,  circumscribed 
pain,  increased  upon  inspiration  by  manual  ])rcssurc  applied  to  the 
sternum,  -which  causes  the  fragment  to  spring  out  and  increase  the  pain  ; 
diaphragmatic  and  abdominal  breathing;  crepitus,  heard  l)y  the  stetho- 
scope j)laced  over  the  fracture,  or  felt  by  jdacing  the  jialm  of  the  hand 
over  the  fracture  while  the  patient  coughs  ;  and  also  abnormal  outline  of 
the  chest  side-wall.  If  the  fracture  happens  to  be  compound  or  from  a 
gunshot  \\ound,  hemorrhage  from  the  seat  of  fracture  is  a  jn'ominent 
sign.  This  hemorrhage  may  originate  from  a  wounded  intercostal 
artery,  in  which  case  the  lilood  is  bright  red  in  color,  and  comes  in  spurts 
synchronous  with  the  action  of  the  heart,  or  else  the  hemorrhage  may 
come  from  wounded  lung-tissue,  in  which  case  the  blood  wells  up  from 
the  bottom  of  the  \\ound  and  is  very  dark  in  color,  due  to  the  presence 
of  carbonic  acid. 

Among  the  general  signs  and  symptoms  are  hsemoptysis,  or  the  ex- 


SPECIAL  FRACTURES.  575 

pectoration  of  blood  from  the  wounded  lung ;  and  emphysema,  or  the 
escape  of  air  from  the  lung  into  the  surrounding  tissue.  The  emphysema 
is  first  noticed  upon  the  side  of  the  chest-wall,  and  it  may  extend  to  the 
neck,  and  even  over  the  abdomen.  The  writer  has  on  several  occasions 
observed  air  in  the  connective  tissue  as  far  down  as  the  scrotum,  although 
it  is  not  liivcly  to  go  below  Poupart's  ligament.  Pneumothorax  and 
htemothorax  also  may  be  present  in  fracture  of  the  rib.  It  is  apparent 
that  these  general  signs  indicate  the  presence  of  a  complicated  fracture. 
Occasionally  pulmonary  apo[)lexy  and  ])ulmonary  enii)hysema  may  also 
be  found  in  fracture  of  tlie  rib. 

Tlie  treatment  of  fracture  of  the  rib  sluiuld  be  directed  to  tlic  relief 
of  pain,  to  tile  diminution  of  the  respiratory  movcnuMits,  to  the  fixation 
of  the  fragments,  to  the  arrest  of  hemorrhage,  and,  finally,  to  the  antici- 
pation of,  as  well  as  to  the  control  of,  inflammatory  complications.  Witli 
a  view  to  the  first  and  second  objects  opium  is  indicated.  This  drug  is 
the  sheet-anchor  in  tliis  fracture,  because  it  not  only  relieves  pain  by  its 
specific  action  and  by  its  reducing  tlie  number  of  the  respirations,  but  it 
also  has  a  salutary  influence  upon  inflammatory  reaction.  M'itii  a  view 
to  accomplishing  tiie  third  object — viz.  the  fixation  of  the  fragments — a 
six-inch  broad  and  a  three-feet  long  strip  of  rubber  or  adhesive  plaster 
should  be  applied  around  the  chest,  the  centre  of  which  strip  should 
pass  over  the  site  of  tlie  fracture.  The  plaster  should  l)e  tightened  dur- 
ing forced  expiration,  so  tliat  upon  inspiration  tlie  injured  cliest-wall  will 
have  a  firm  support.  This  simjile  apj)aratus  attbrds  tiie  greatest  possible 
comfort  to  the  patient.  Tiie  heiuorriiage,  if  pulmonary,  can  be  controlled 
by  packing  the  wound  with  iodoform  gauze  in  the  form  of  a  tampon ;  if 
arterial,  the  wound  must  be  enlarged  so  as  to  .secure  both  ends  of  the 
divided  intercostal  artery.  In  case  the  vessel  cannot  be  found,  a  square 
piece  of  gauze  aliout  tlie  size  of  a  sheet  of  letter-paper  can  be  introduced 
into  the  wound  and  beyond  the  rib  by  forcing  it  with  a  director  placed 
in  the  centre  of  tiie  piece  of  gauze.  Into  tliis  glove-finger-shaped  piece 
of  gauze  small  narrow  .strips  of  iodoform  gauze  can  be  pushed,  and  when 
the  bottom  of  the  glove-finger  tampon  is  well  filled  the  entire  compress 
can  be  partially  withdrawn  until  it  comes  in  contact  with  the  inner  sur- 
face of  tlu>  upper  and  lower  rilis  in  tiie  interspace.  Tlie  pressure  can 
now  be  made  directly  upon  tlie  l)leeding  vessel.  This  tampon  can  be 
subsequently  removed  by  diminishing  its  size  by  removing  some  of  the 
narrow  strips  of  gauze  with  wliich  the  glove-finger  has  been  packed. 

The  emphysema  is  not  to  be  interfered  with,  since  the  air  will  event- 
ually become  ab.sorbed,  and,  altiiough  the  patient  may  be  unrecognizable 
on  account  of  the  general  swelling,  tlie  condition  itself  gives  no  cause 
for  alarm.  It  occasionally  hapjiens  tliat  the  air  is  so  freely  distrilmted 
that  wiien  it  reaches  the  'loose  cellular  tissue  of  the  neck  respiration  is 
seriously  embarrassed,  and  in  this  ease  a  few  incisions  through  the 
integument  will  suffice  to  allow  the  air  to  escape.  It  is,  however,  only 
under  extraordinary  circumstances  that  incisions  should  be  made,  since 
this  apparently  simple  procedure  has  been  followed  by  death.  If  the 
emphysema  invades  the  mediastinnm  or  forces  its  way  into  the  inter- 
lobular tissue  of  the  lung,  tliis  condition  is  not  amenable  to  surgical 
treatment  and  forms  a  most  serious  complication. 

In  fracture  of  the  ribs  in  which  there  is  little  or  no  collapse,  and  the 


576  FRACTURES. 

patient  is  a  strong,  pletiioric  individual  and  suffering  from  dyspnoea  and 
impending  asphyxia,  venesection  is  indicated,  and  will  remove  at  once 
tlie  alarming  distress  and  discomfort,  since  by  this  means  the  venous 
congestion  and  pulmonary  engorgement  are  innnediately  relieved. 

The  coHtal  cdiiildt/c^  may  be  fractured,  either  at  their  junction  with 
the  rib  or  even  in  the  middle  of  the  cartilage  itself.  The  fracture  of 
the  cartilage  is  jirodueed  by  the  same  causes  as  fracture  of  the  ribs,  and 
the  signs  and  symptoms  and  treatment  are  similar. 

FitACTURE  OF  THE  STERNUM  occurs  in  less  than  1  per  cent,  of  all 
fractures.  This  is  owing  to  the  elasticity  atibrded  to  it  by  its  connec- 
tions with  the  ribs,  and  also  to  its  sjiongy  structure.  It  may  be  caused 
by  direct  violence,  as  a  heavy  blow  upon  the  chest,  or  by  a  heavy 
weight  falling  upon  the  patient,  or  by  a  gunshot  wound.  This  injury 
has  also  been  observed  as  the  result  of  indirect  violence,  as  in  bending 
the  body  suddenly  liackward  or  forward,  and  occasionally  a  fracture  has 
been  observed  after  a  fall  Tijion  the  shoulder,  in  which  case  the  force  is 
transmitted  along  the  clavicle  and  ribs.  Several  cases  of  fracture  of 
this  bone  have  been  reported  as  a  result  of  muscular  action  during 
labor-pains.  A  case  has  also  been  reported  where  the  patient  fractured 
the  sternum  by  endeavoring  to  lift  a  weight  with  the  teeth  while  the 
body  was  placed  in  the  position  of  ojjisthotonos. 

The  fracture  is  usually  simple  and  transverse,  and  it  is  generally 
situated  at  the  junction  of  the  manubrium  with  the  l)ody  of  the  bone 
(Fig.  87).  If  the  fracture  is  due  to  a  gunshot  wound,  it  may  of  course 
be  situated  at  any  part  of  the  bone.  It  sometimes  happens  that  the  lower 
extremity  of  the  bone  or  the  ensiform  cartilage  is  the  ]iart  broken. 

The  displacement  is  usually  slight,  on  account  of  the  periosteum  in 
fi'ont  and  behind  the  bone.  The  lower  fragment  is  usually  displaced 
forward  and  (iverla))s  the  lower  margin  of  the  ui>per  fraoment. 


-'» 


Tiie  signs  and  symptoms  of  fracture  of  the  sternum  are — fixed  jiain, 
which  is  increased  by  a  deep  inspiration  or  expiration  ;  cough,  attended 
by  expectoration  of  blood  and  marked  irregularity  of  the  action  of  the 
heart,  with  dys}>nwa  ;  flexion  forward  of  the  head  and  trmik  ;  change  in 
the  outline  of  the  bone  ;  and  crepitus,  felt  by  placing  the  jwhn  of  the 
hand  over  the  sternum  while  the  ])atient  coughs.  In  some  cases,  how- 
ever, crepitus  can  be  detecteil  only  by  means  of  the  stethoscope. 

The  prognosis  in  this  fracture  is  favorable,  unless  it  is  complicated 
with  a  fracture  of  the  sjiinal  colunui  or  the  ribs  or  the  clavicle,  or  by  a 
hemorrhage  into  the  anterior  mediastinum. 

The  treatment  consist  in  the  application  of  a  liroad  band  of  adhesive 
plaster  placed  around  the  chest  in  the  manner  already  described  in  the 
dressing  of  a  fractured  rib.  It  may  be  necessary  to  a]>j)ly  a  compress  to 
the  fragment  which  is  tilted  forward,  and  this  dressing  will  maintain  the 
apposition  of  the  fragments.  In  reducing  the  fracture  the  jjatient  should 
be  placed  in  the  position  of  opisthotonos,  with  a  hard  jiillow  under  the 
back.  In  this  attitude  of  the  body  the  advancing  fragment  can  be  brought 
into  coaptation  with  the  receding  fragment.  The  suggestion  of  Petit,  of 
cutting  dt)wn  upon  the  bone  and  elevating  the  fragment,  or  that  of  Nelaton, 
of  passing  a  hook  under  the  fragment,  is  not  to  be  recommended.  The 
dangers  of  injury  to  the  pleui'a  and  pericardium,  of  suppuration  in  the 
anterior  mediastinum,  and  of  conversion  of  a  simple  into  a  compound  frac- 


SPECIAL  FRACTURES.  577 

ture,  are  too  great  risks  to  run  to  relieve  a  deformity  which  ordinarily  pro- 
duces no  disturbance.  Trepliining  of  the  sternum  is  likewise  to  be  con- 
demned, as  well  as  the  use  of  the  gimlet,  since  these  measures  have  been 

Fig.  87. 


Displacement  of  fragment.s  in  fracture  of  sternum. 


attended  with  serious  result.  Tlic  movements  of  respiration  should  be 
dimiui.-ihed  by  the  use  of  opium,  and  the  |)aticnt  |ilaccd  in  the  ])ositiiin  in 
whicii  he  can  breathe  witii  the  least  difficulty. 

FR.vcTrRp:s  of  the  clavicle  occur  in  about  lo  per  cent,  of  all 
fractures.  They  are  common,  because  the  bone  is  prominently  ex]50sed, 
and  receives  all  shocks  transmitted  to  it  by  falls  ujion  the  shoulder,  elbo\\', 
and  hand.     This  injury  also  occurs  from  direct  violence,  as  a  blow  upon 

Vol.  L— 37 


5/8  FRACTURES. 

the  shoulder  or  by  a  heavy  weifi;ht  falliiij;-  u]W)ii  it,  and  has  been  known 
to  result  from  nuisciilar  aetioii,  on  aeeount  of  the  strong  contraction  of 
the  deltoid  and  the  clavicular  ])ortion  of  the  pectoralis  major,  an 
example  of  which  is  reported  in  an  atteni])t  to  lift  a  carriage-top  while 
seated  in  the  carriage.  Fractures  of  the  clavicle  are  rare  in  elderly 
pe(i])le,  and  exceedingly  comnicm  in  rhildrcii,  in  wliom  half  of  tlie  cases 
occur  before  the  fiftli  year. 

The  seat  of  the  fracture  may  be  in  the  body  of  the  bone  or  at  the 
acromial  or  sternal  extremity.  The  most  frequent  .seat  of  fracture  of  the 
clavicle  is  in  the  body  of  the  bone  just  external  to  the  centre,  since  at 
this  place  the  bone  is  least  in  diameter,  and  at  the  same  time  it  is  the 
junction  of  the  outer  and  sudilcn  curve  with  the  inner  curve.  This  is 
the  case  upon  exposure  to  indirect  violence,  while  following  direct  vio- 
lence any  portion  of  the  bone  may  be  broken  ;  but  the  sternal  end  is  less 
frecpiently  broken,  since  the  direct  force  of  a  blow  upon  the  shoulder  is 
usually  attended  by  fracture  of  the  acromial  end,  which  receives  the  full 
force  of  the  injury. 

The  fracture  is  generally  simj)lc,  altiiough  the  writer  has  seen  two 
cases  of  compound  fracture,  excluding  gunsiiot  fractures.  The  double 
curve  in  the  body  of  the  clavicle  prevents  it  from  breaking  as  often 
as  if  it  were  perfectly  straight,  since  the  curves  transmit  the  force  over 
a  greater  space.     It  is  a  noteworthy  fact  that  it  seldom  happens  that 

Fig.  S8. 


Displacement  of  inner  and  outer  fragments  in  fraeture  of  clavicle. 


fracture  of  the  clavicle  is  associated  with  other  injuries,  such  as  fracture  of 
the  adjacent  ril)s,  injury  of  tlie  pleura,  laceration  of  the  important  axillary 
vessels,  or  stretching  of  the  cords  of  the  brachial  plexus.  Any  or  all  of 
these  complications  may  occur,  but,  considering  the  frequency  of  fracture 
of  the  clavicle,  it  is  extremely  rare  to  find  any  of  these  concomitant 
injuries. 

The  displacement  in  fractures  of  the  clavicle  consists  of  an  elevation 


SPECIAL  FRACTUBES.  579 

and  projection  of  the  sternal  end  of  the  hone  by  the  aetion  of  the  clavic- 
ular portion  of  the  sterno-eleido-mastoid  muscle  (Fig.  88),  and  a  depres- 
sion of  the  acromial  extremity  by  the  weight  of  the  arm  and  by  the  action 
of  the  pcctoralis  minor  muscle,  and  also  by  the  lower  fibres  of  the  pectoral  is 
major  and  the  deltoid  acting  from  its  humeral  insertion.  The  outer  frag- 
ment is  also  rotated  by  tlie  action  of  the  scrratus  magnus  muscle,  which 
has  a  tendency  to  draw  backward  the  inner  extremity  of  the  outer  frag- 
ment ;  which  fact  explains  the  frequency  with  which  the  fragment  per- 
forates the  loose  skin  over  the  clavicle,  and  thus  causes  a  compound 
fracture. 

The  signs  and  symptoms  of  fracture  of  the  clavicle  vary  some- 
what according  to  the  special  seat  of  the  fracture.  Besides  the  ordinary 
signs  indicative  of  fracture,  there  are  some  special  signs  and  symptoms 
which  are  characteristic,  among  which  may  be  mentioned  the  interrup- 
tion in  the  line  of  the  bone;  the  loss  of  power  in  the  muscles  attached  to 
it ;  the  flattening  and  depression  of  the  shoulder,  which  falls  downward 
by  the  weight  (if  the  arm,  inward  by  the  action  of  the  pectoralis  minor 
and  the  subelavius,  and  to  some  extent  of  the  pectoralis  major  nuiscle, 
and  forward,  on  account  of  the  shape  of  the  thorax  ;  and,  finally,  the 
turning  of  the  head  and  neck  toward  the  injured  side  in  order  to  relax 
the  muscles,  which  cause  pain  by  their  contraction.  Among  other  signs 
may  be  mentioned  the  nearer  approach  of  the  affected  shoulder  to  the 
mesial  line  of  the  sternum,  the  close  proximity  of  the  arm  to  the  side 
of  the  chest,  and  the  loss  of  th.e  support  of  the  elbow,  which  is  generally 
held  up  by  the  patient's  other  hand. 

The  treatment  of  fracture  of  the  clavicle,  on  account  of  its  extreme 
frequency,  has  commanded  the  attention  of  surgeons  in  every  country. 
The  different  kinds  of  apparatus  and  appliances  all  aim  to  bring  the 
shoulder  upward,  outward,  and  backward  in  order  to  overcome  the  dis- 
placement, which  is  downward,  inward,  and  forward.  Tf  a  jxitient  will 
consent  to  lie  on  his  back  in  bed  for  two  weeks  upon  a  firm  and  hard  mat- 
tress, with  a  small  pillow  under  the  head,  and  the  affected  arm  held  close 
to  the  side  of  the  chest  by  a  long,  heavy  sand-bag,  this  supine  position 
will  accomplish  more  satisfactory  results  than  any  dressing  yet  devised. 
The  recumbent  position  upon  the  back  causes  the  shoulder  to  assume  its 
normal  relation.  A  sand-bag  placed  over  the  point  of  the  shoulder  will 
assist  l)V  depressing  it,  and  tlicrcby  bringing  the  fragments  into  apposition. 
The  results  obtainctl  by  this  simple  method  are  far  superior  to  those 
obtained  by  any  other,  since  the  fragments  unite  without  any  overlap- 
ping and  the  callus  is  not  so  exuberant ;  and  in  the  case  of  a  lady,  in 
whom  the  recjuirements  of  dress  compel  her  to  expose  her  neck,  the  dis- 
figurement of  a  callus  is  sometimes  more  dreaded  than  the  forced  con- 
finement in  bed  for  t\\'o  weeks.  It  is  only  occasionally  that  a  woman's 
vanity  will  induce  her  to  choose  this  mctiiod  of  treatment. 

li'  the  patient  will  not  consent  to  remain  in  bed,  the  best  and  simplest 
method  is  that  of  Sayre,  who  describes  his  dressing  in  the  following 
manner:  "  After  drawing  the  arm  backward  and  retaining  it  tiiere  by 
a  sti-i]i  of  adhesive  ])laster,  pass  another  piece  of  plaster  from  the  well 
shoulder  across  the  l)ack,  and  by  pressing  the  elbow  well  forward  and 
inward  the  first  ])Iaster  around  the  middle  of  the  arm  is  made  to  act  as 
a  fulcrum,  and  the  simuldcr  is  necessarily  carried  upward,  outward,  and 


580 


FRACTURES. 


backward  ;  and  the  plaster,  being'  cari-icd  o\'er  the  elbow  and  forearm 
(wliieli  i.s  flexed  across  the  chest)  to  the  opposite  siioulder,  the  place  of 
starting,  and  then  secured  by  pins  or  stitches,  permanently  retains  the 

parts  in  position Strong  and  good  adhesive  ])laster  is  cut  into 

two  strips  three  to  four  inches  wide  (narrower  for  children),  one  piece  long 
enough  to  surround  tlie  arm  and  go  (•(ini]>letely  annuid  tlie  body,  the  otlier 
to  reach  from  the  sound  shoulder  around  the  elbow  of  the  fractured  side  and 
back  to  the  place  of  starting.  The  first  piece  is  passed  around  the  arm  just 
below  the  axillary  margin,  and  pinned  or  stitched  in  the  form  of  a  loop  suffi- 
ciently large  to  prevent  strangulation,  leaving  a  portion  on  the  back  of  the 
arm  uncased  by  the  ])laster.  The  arm  is  then  drawn  downward  and  back- 
ward until  the  clavicidar  jiortion  of  the  pectoralis  major  muscle  is  put  suf- 
ficiently on  the  stretch  to  overcome  the  sterno-cleido-mastoid,  and  thus 
pull  the  inner  portion  of  the  clavicle  down  to  its  level.  The  plaster  is 
then  carried  smoothly  and  completely  around  the  body,  and  pinned  to 
itself  on  the  back  to  prevent  slipping,  as  seen  in  Fig.  89.     Tlie  first 

Fig.  89. 


Savre's  adhesive-plaster  dressing  for 
'fracture  of  elaviele  (first  piece}. 


Ihe  same  (secund  piece). 


strip  of  plaster  fulfils  a  double  purpose  :  first,  by  jiutting  the  clavicular 
portion  of  the  ])ectoralis  major  muscle  on  the  stretch,  it  prevents  the 
clavicle  from  riding  upward  ;  and  secondly,  acting  as  a  fulcrum  at  the 
centre  of  the  arm  \\-hcn  the  elbow  is  pi'essed  downward,  forward,  and 
inward,  it  neces.sarily  foi'ces  the  other  extremity  of  the  humerus  (and 
with  it  the  shoulder)  upward,  outward,  and  backward  ;  and  it  is  kept  in 
this  position  by  the  second  strip  of  plaster,  which  is  applied  as  follows : 
Commencing  on  the  front  of  the  shoulder  of  the  sound  side,  draw  it 
smoothly  and  diagonally  across  the  back  to  the  elbow  of  the  fractured 
side,  where  a  slit  is  made  in  its  middle  to  receive  the  projecting  olec- 
ranon. Before  applying  this  plaster  to  the  elbow  an  assistant  shouhl  ]>ress 
the  elbow  Avell  forward  and  inward  (Fig.  90),  and  retain  it  there  while 


SPECIAL  FRACTURES. 


581 


Fig.  91. 


the  plaster  is  continued  over  tlie  elbow  and  forearm  (pressinfj  the  latter 
close  to  the  chest  and  .securing  the  hand  near  the  opposite  nipple) ;  cros.s- 
ing  the  shoulder  at  the  place  of  beginning,  it  is  there  secured  by  two  or 
three  pin.s,  as  seen  in  Fig.  90. 

"When  this  has  been  done  the  dcfurniity  will 
have  entirely  disappeared,  the  fractured  bones 
will  be  accurately  adjusted,  and  as  long  as  the 
strips  of  plaster  maintain  their  position  no 
amount  of  force  can  displace  them." 

Velpeau's  dressing  is  made  by  means  of  a  long 
roller  bandage.  The  patient's  hand  is  placed 
upon  his  opposite  shoulder,  the  elbow  against 
the  front  of  the  chest,  and  a  bandage  is  started 
in  the  opposite  axilla  and  carried  obliquely 
across  the  back  over  the  affected  shoulder  (Fig. 
91),  down  in  front  of  tlie  arm,  and  under  the 
elbow  tn  the  other  axilla.  After  the  arm  is 
thus  vertically  bandaged  and  brought  snugly 
against  the  chest,  the  roller  is  carried  in  a 
circular  manner  around  the  thorax  from  below 
upward  until  the  arm  and  the  forearm  are  cov- 
ered by  this  bandage  as  high  as  the  axilla  on  the  unaffected  side  per- 
mits. Tills  entire  dressing  can  be  made  stiff  by  the  applit-ition  of  loose 
plaster  or  silicate  of  soda,  or  even  by  stitching  it  in  many  places,  so 
that  tlie  roller  will   not  l)ecome  displaced  by  slipping. 

Moore's   dressing    consists   of  a  figure-of-8  bandage  (Figs.  92  and 

Fig.  92.  Fig.  93. 


Velpeau's  dressing  for  frac- 
ture of  the  clavicle. 


Jloore's  dressing  for  fractured  clavicle. 


Moore's  dressing  for  fractured  clavicle. 


93),  a  detailed  description  of  wiiich,  in   his  own   words,  is:   "  T  use  a 
shawl  or  piece  of  cotton  cloth,  whicii,  wlien  folded  like  a  cravat  eight 


582  FRACTURES. 

inches  in  bivndtli  at  tlie  centre,  slicmld  Ite  alxmt  two  yards  long. 
Plaeint;  this  at  tlie  centre  across  the  ])aliii  of  tlie  suri;'eon,  he  seizes  witii 
tliis  iiand  tiie  elhow  of  the  jiatient  wliieii  corresponds  with  the  liroken 
cla\'iclc.  'I'lic  two  ends  of  tlie  hantlaii'c  hang  to  tiie  floor.  Tiie  one 
falling  inward  toward  tlie  patient  is  carried  upward  in  front  of  the 
shouhler  and  over  the  back,  making  a  spiral  movement  in  front  of  the 
shoulder.  This  is  entrusted  to  an  assistant.  The  outer  end  is  then 
carried  across  the  forearm,  beliind  the  back,  over  the  ojijwsite  shoulder, 
and  around  the  axilla.  Tiiis  meets  tiie  other  end,  wliicii  niav  be  carried 
under  the  axilla  and  over  the  shoulder  of  the  opposite  side,  thus  making 
the  tigure  (8)  turn  around  the  sound  shoidder.  This  twist,  it  will  be 
seen,  also  makes  the  tigure  (8)  turn  around  the  elbow  of  the  affected 
side." 

Fracture  of  the  scapula  is  rare,  on  account  of  the  mobility  of 
the  bone,  the  elasticity  of  the  ribs,  the  protection  which  is  atforded  to  it 
by  tiie  cushion  of  muscles  upon  its  dorsal  surface,  and  the  support 
which  it  has  from  the  thoracic  wall. 

Fractures  of  the  scapula  are  caused  usually  by  direct  violence, 
although  a  case  has  been  reported  in  which  the  fracture  was  said  to 
have  occurred  as  a  result  of  muscular  action. 

The  varieties  of  fracture  of  the  scapula  are — fif  the  body,  of  the 
acromion  process,  of  the  coracoid  process,  and  of  the  neck  of  the  bone. 
When  the  body  is  fractured  the  line  of  fracture  is  usually  just  below 
the  spinous  process  (Fig.  94). 

Fig.  94. 


Fracture  of  borty  ot  s(  nimla. 


The  signs  and  symptoms  are — crepitus,  pain,  dis])lacement,  and 
ecchymosis.     The  crepitus  is  found  by  placing  the  palm  of  one  hand 


SPECIAL  FRACTURES.  583 

iipiin  tlie  back  over  the  seapiila  ami  moving  the  arm  witli  the  otlier 
hand. 

The  chsphicement  consists  of  the  drawing  upward  and  forward  of 
the  lower  fragment  by  the  action  of  the  scrratus  magnus  and  the  teres 
major  muscles,  and  the  drawing  backward  and  upward  of  the  upper 
fragment  hv  the  rhoml)oideiis  major  nuiscle. 

The  treatment  of  fracture  of  tiie  body  of  the  scapula  is  tlie  same 
as  that  described  for  fracture  of  the  rib,  with  the  addition  of  a  compress 
over  the  body  of  the  bone.  The  above-mentioned  muscles  causing  the 
displacement  should  be  relaxed  by  position.  It  has  been  suggested  to 
place  a  gutta-percha  mould  over  the  bone,  an<l  thus  hold  it  in  sitil  until 
tiie  fracture  has  lieen  repaired. 

Fracfnre  of  the  acromion  prooe^s  is  the  result  of  direct  violence,  and 
may  involve  the  tip  of  the  process  only  or  tlie  entire  thickness  in 
a  transverse  or  an  (iblique  direction. 

The  signs  and  symptoms  are — pain,  crepitus,  ecchymosis,  flattening 
and  falling  downward,  forward,  and  inward  of  tlie  point  of  the  shoulder, 
inability  to  raise  the  arm,  and  interruption  of  tiie  line  of  the  spinous 
process  as  felt  by  the  finger  passe<l  over  the  surface.  Any  movement  of 
tile  shoulder  will  lie  attended  witli  great  ])aiii,  and  crepitus  is  distinctly 
felt.  These  signs  are  well  marked  when  the  fracture  of  tiie  acromion  is 
behind  the  acromio-clavicular  articulation,  but  when  in  front  of  this 
ligament  the  displacement  and  the  signs  are  not  so  pronounced. 

The  treatment  consists  in  elevation  of  the  elljow,  while  at  the 
same  time  a  pad  is  jilaced  l)etweeii  tiie  elliow  and  the  thoracic  wall. 
The  elevation  is  maintained  by  a  baiulage  from  tiie  elliow  to  the  opposite 
shoulder.  This  makes  the  head  of  the  humerus  act  as  a  splint  against 
the  broken  acromion.  A  pad  sliould  not  be  jilaced  in  the  axilla,  since 
this  would  have  a  tendency  to  draw  the  head  of  the  humerus  too  far 
outward,  and  then  it  would  not  act  as  a  splint.  The  fragment  of  the 
acromion  should  be  strapped  down  by  strips  of  adhesive  plaster  pulled 
down  with  coiisideral)le  strength.  If  tlie  ])atient  will  submit,  a  most 
desirable  result  can  be  obtained  liy  placing  liim  upon  his  back,  and  then 
bringing  the  arm  out  at  a  riglit  angle  to  the  trunk.  This  position 
relaxes  the  deltoid  muscle  and  brings  the  fragment  into  apposition. 

The  eoracoid  procefi>!  is  rarely  fractured.  The  accident  is  usually  the 
result  of  direct  violence.  The  apex  of  the  process  is  jiulled  downward 
ami  inward  by  the  action  of  the  pectoralis  minor,  the  short  head  of  the 
biceps,  and  the  coraco-brachialis  muscles.  It  sometimes  happens  that 
little  if  any  displacement  is  noticed,  since  the  strong  coraco-clavicular 
ligament  remains  untorn  and  the  dense  periosteal  and  fibrous  tissue  holds 
the  fragments  in  place. 

Tile  signs  and  symptoms  consist  of  crepitus,  mobility  of  the  process, 
marked  impairment  in  tlie  movements  of  the  arm,  and  the  stationary 
position  of  tlie  fragment  when  the  arm  is  passively  moved. 

The  treatment  consists  in  flexing  the  forearm  ujion  the  arm,  and 
then  drawing  well  forward  tlie  elbow  ujion  tlie  antero-lateral  part  of  the 
chest.  This  position  relaxes  the  two  muscles  having  their  origin  from, 
and  insertion  into,  the  coracoid  process. 

Fracfnre  of  the  snrc/ical  neck  of  the  scapula  (Figs.  95,  96)  occasion- 
ally occurs,  and  often  in  conjunction  with  a  fracture  of  the  floor  of 


584 


FRACTURES. 


the  glenoid  eavitv.  Tlie  fraeture  may  he  situated  at  tlic  anatomical 
or  surgical  neck,  the  anatomical  necU  consisting  ot"  tliat  part  of  tiie 
bone  which  is  external  to  tiie  coracoid  process,  and  just  beliind  tiie 
glenoid  fossii,  tlie  surgical  neck  end)racing  tlie  anatomical  neck  and 
inchKliny:  the  coi 


d 


I'ta.  95. 


procc 


Thus  A  fracture  of  the  anatomical  neck 
Fio.  9(1. 


Fracture  of  tlic  nock  of  the  scapula  (according  to 
Sir  A.stley  Cooper). 


Comniinutcrl   fnu'tvirc  of  the 
cavity. 


enoid 


would  cause  a  separation  of  the  glenoid  cavity  only,  while  that  of  the 
surgical  neck  would  involve  the  coracoid  process.  This  fact  must  not 
be  overlooked,  since  the  disjilaeement  in  case  of  fraeture  of  the  surgical 
neck  is  well  jjronounced,  wiiile  tliere  is  little  deformity  if  only  the 
anatomical  neck  is  fractured.  The  cause  of  this  fractm-e  is  liy  direct 
violence,  either  from  a  blow  upon  the  shoulder  or  from  a  fall  from  a 
height  in  which  the  patient  strikes  upon  the  shoulder. 

The  signs  and  s3miptoms  eon.sist  of  a  flattening  of  the  shoulder, 
simulating  a  dislocation  ;  jii'ominence  of  the  acromion,  with  a  slight 
sulcus  beneath  it  sufficient  to  receive  the  index  finger  placed  laterally 
under  it;  lengthening  of  the  arm  ;  the  movement  of  the  coracoid  process 
with  the  humerus  ;  crepitus  produced  by  elevation  of  the  elbow  and  rota- 
tion of  tiie  humerus ;  the  eomj)lcte  restoration  of  the  landmarks  of  the  joint 
by  lifting  the  arm  at  the  elbow,  and  their  immediate  loss  ujion  removal 
of  the  support ;  and  the  presence  of  the  glenoid  cavity  felt  in  the  axilla. 

The  treatment  consists  in  elevation  of  the  elbow  after  flexion  of  the 
forearm  upon  the  arm,  fixation  of  the  i^cajtula  by  means  of  compresses 
held  in  place  by  strips  of  rubber  plaster,  and  the  adjustment  of  a  pad  in 
the  axilla. 

The  Velpeau  dressing,  as  used  in  fracture  of  the  clavicle,  is  an  excel- 
lent dressing  for  this  injury,  since  it  supports  the  arm  and  causes  lateral 
pressure  of  the  arm  to  the  chest-wall. 

P^RACTUREs  OF  THE  HUMERUS  form  about  8  percent,  of  all  fractures, 
and  the  classification  is  similar  to  that  of  fractures  of  the  femur :  in  the 
U])per  third,  according  to  the  seat  of  fracture,  thus :  fracture  of  the 
anatomical  neck,  of  the  tuberosity,  of  the  surgical  neck,  and  epiphyseal 


SPECIAL  FRACTURES. 


585 


separation  ;  in  the  middle  third,  according  to  the  variety  of  tlie  fractnre, 
thus :  simple,  compound,  cunmiinuted,  and  complicated  ;  in  the  lower 
third,  according  to  the  part  fractured,  thus :  external  and  internal 
condyloid  fractures,  supra-condyloid  fracture,  and  epiphyseal  sejtaration. 

FradnrvK  of  f/ic  Luirrr  End  of  the  Hninerun. — Epiphi/sca/  Sepani- 
tion. — Epiphyseal  separation  is  likely  to  ha])pen  Ijcfore  the  eighteenth 
year,  and  may  occur  in  the  form  of  a  detachment  of  the  articular 
extremity  from  the  diaphysis.  The  condyles  remain  attached  to  the 
shaft,  since  they  undergo  ossification  by  separate  centres,  or  the  condyles 
witli  the  articular  extremity  may  become  detached  from  the  shaft  of  the 
humerus.  In  some  respects  e]Mphyscal  se|)aration  resembles  a  supra- 
eondyliiid  fracture  or  a  backwanl  dislocation  of  the  forearm.  In  incom- 
plete epiphyseal  separation  the  forearm  is  Hexed,  and  assumes  a  position 
midway  between  supination  and  pronation,  while  the  normal  relations 
which  exist  between  the  condyles  and  the  olecranon  are  destroyed.  The 
measurement  of  the  forearm  reveals  shortening  between  the  condyles 
of  the  humerus  and  the  styloid  processes  of  tlie  radius  ami  the  ulna.  In 
the  eomitlete  epi])!iyseal  separation  tlie  relations  which  exist  l)etween  the 
condyles  and  the  olecranon  are  not  disturbed,  since  the  separation  occurs 
above  the  condyles.  The  differential  points  between  the  fi'actures  in  this 
region  on  the  one  hand,  and  a  backward  dislocation  of  the  forearm  on 
the  other,  are  the  tendency  of  the  deformity  to  return  in  fractures  as 
soon  as  reduced,  and  the  ditfieulty  of  maintaining  perfect  apposition 
even  with  suitable  splints;  also  the  preternatural  mobility,  crepitus, 
shortening  of  the  arm  from  the  acromion  to  the  condyle,  and  more  or 
less  rigidity  of  the  muscles,  with  ecchymosis  over,  and  swelling  in,  the 
elbow-joint. 

A  dislocation  of  both  liones  of  the  forearm  backward  is  distinguished 
from  epiphyseal  separation  by  immobility,  absence  of  crepitus,  no  altera- 
tion in  the  length  of  the  shaft  of  the  humerus,  the  great  prominence  of 
the  olecranon,  which  is  nearer  to  the  acromion  than  upon  the  opposite 
side,  and  the  greatly  altered  relations  of  the  olecranon  process  and  the 
condyles. 

The  treatment  of  epiphyseal  separation  is  the  same  as  that  of  supra- 
condyloid  fracture,  since  the  two  injuries  require  practically  the  same 
kind  of  surgical  dressing. 

Svpni-coiithihiid  fr<(rii(iT  is  usually  trans- 
verse, but  it  is  at  the  same  time  oblique  from 
above  downward  and  forward. 

The  signs  and  symptoms  are  in  some 
respects  similar  to  the  l)ackward  displace- 
ment of  both  bones  of  tlie  forearm  (Figs.  97, 
98,  and  99).  The  diagnostic  signs  of  supra- 
condyloid  fracture  'are  the  ])rojection  of  the 
olecranon,  the  swelling  in  front  of  the  elbow- 
joint,  slight  flexion  of  the  forearm,  prona- 
tion of  the  hand,  and  inability  to  flex  the  fore- 
arm. Marked  crepitus  is  elicited  by  flexion  and  extension  of  the  forc- 
ami.  The  signs  which  distinguish  this  injury  from  dislocation  of  both 
bones  of  the  forearm  backward  have  Iteeu  enumerated  in  connection 
with  ejiiphyseal  separation.     It  sometimes  luippens  that  a  vertical  frac- 


FiG.  97 


Supra-eondyloid   fracture  of  the 
hnmenis  (Hutchinson). 


586 


FRACTURES. 


ture  occurs  in  connection  witli  tlic  sii])rn-con(lyloi(l  fVacturc,  in  which  tlie 
line  of"  fracture  extends  downward  between  the  two  condyles,  forming 
what  is  called  a  "  T-sliaped  fracture"  (Fig.   lOOj.     This  injury  results 


Fio.  9S. 


Fio.  99. 


Supra-condyloid  fracture  of  the 
humerus. 


.Supra-coiKl.i  i..,..  11..'  iiuv  nf  the  humerus: 
union  with  displacement. 


from  direct  violence  which  is  applied  posteriorly,  and  is  also  seen  in 
gunshot  fractures.  The  additional  .signs  of  this  complication  consist  of 
an  increase  in  the  breadth  of  tlie  condyloid  extremity  of  the  lower  end  of 
the  humerus  and  .severe  joint-inflammation  attended  with  great  effusion. 
The  treatment  of  supra-condyloid  fracture  after  comj)lete  reduction 
consists  in  the  application  of  a  well-padded  anterior  angular  splint  and  a 

Fig  100. 


T-fracture  above  the  condyles  and  extending  into  elbow-joint. 


short  posterior  splint,  with  the  forearm  flexed  to  a  right  angle  upon  the 
arm  and  the  hand  placed  in  the  supine  position.  Some  surgeons  advise 
the  use  of  the  internal  angular  splint  with  the  forearm  placed  midway 
between  jironation  and  supination  and  the  ])alm  of  the  hand  pointing 
inward  and  the  thumb  upward.  Passive  motion  sliould  not  be  em])loyed 
until  tiie  end  of  the  fourth  week,  as  the  fracture  does  not  extend  into  the 
ell)ow-joint,  and  such  movement  before  consolidation  has  taken  place  is 
likely  to  disturb  the  union  of  the  fragments. 

Internal  condi/loid  fractior  occurs  as  a  result  of  direct  violence,  and 
the  line  of  fracture  generallv  extends  downward  and  outward  to  the  tro- 


SPECIAL  FRACTURES. 


587 


Fracture  of  the  inter- 
nal epicondyle  of 
the  hiimer\is  (epi- 
trochlea)  (Gurlt). 


chlear  surface  of  the  Immerus,  and  passes  throuo-h  the  olecranon  and 
coronoid  fossae.  Tlie  fragment  is  displaced  upward  and  backward  and 
slightly  inward,  and  it  is  accompanied  by  the  ulna. 

The  signs  are — removal   of   the  internal   condyle  from    its   normal 
position,  crepitus,  moljility,  pain  and  swelling  over  the  internal  condyle, 
increase  in  tiie  breadth  of  the  lower  end  of  the  humeriis 
Fig.  101.  (Fig.  101),  greater  prominence  of  the  ulna  posteriorly 

during  e.xtension  of  the  forearm,  and  a  corresponding 
swelling  upon  the  front  of  the  elbow-joint,  due  to  the 
projection  of  the  lower  end  of  the  humerus. 

The  treatment  of  this  fracture  consists  in  the  apidi- 
cation  of  some  evaporating  lotion  over  the  condyle  and 
the  joint  with  a  view  to  reducing  the  inflammatory  swell- 
ing. As  soon  as  the  inflammation  has  subsided  the  frag- 
ment, consisting  of  the  internal  condyle,  should  be  jjlaced 
in  its  proper  position,  and  held  //(  xitu 
l)y  niean-^of  a  pad.   An  angular  s))lint  Fig.  102. 

siionld  now  be  applied,  with  the  fore- 
arm flexc'l  upon  the  arm  to  a  right 
angle  and  placed  in  the  position  of 
supination,  or  midway  between  pro- 
nation and  supination,  with  the 
thumli  upward.  In  the  use  of  an 
angular  splint  tlie  surgeon  must  guard  against  any 
undue  pressure,  which  might  cause  a  slougii  over 
any  bony  prominence  or  even  gangrene  of  the  Angers. 
Since  this  fracture  involves  the  elbow-joint,  passive 
motion  must  be  instituted  after  the  second  week  in 
order  to  prevent  ankylosis.  In  ease  the  fracture  is 
T-sha]ied,  cold  evaporating  lotions  should  be  first  ap- 
plied, and  after  the  subsidence  of  the  inflammation 
the  fragments  should  be  adjusted  and  the  same  kind 
of  splint  applied.  Ankylosis  follows,  since  no  passive 
motion  can  be  made,  and  the  degree  of  ankylosis  de- 
pends upon  the  amtnuit  of  joint-complication. 

External  condi/loid  fracture  is  often  .seen  in  chil- 
dren. While  it  may  be  the  residt  of  direct  violence, 
it  is  more  often  caused  by  a  fall  upon  the  hand.  It 
usually  involves  the  elbow'-joint,  or  the  fracture  ex- 
tends downward  and  sejwrates  the  capitellum  from 
the  artictdar  surface,  and  the  liead  and  shaft  of  the  Showing  the  transmis- 

,.  ]    .  •      i    ^1  -i    11  rni  sion  through  the  ex- 

racluis  are  driven  up  against  the  ca])itciliim.  J  he  ternai  coiidyie  of  a 
fragment  is  displaced  ujixvard  and  backward  and  [ir/paim'"''"'  "P"" 
slightly  outward  (Fig.  102).  Dr.  Oscar  H.  Allis  has 
called  attention  to  the  deformity  arising  from  impi'oper  treatment  of  frac- 
tures of  the  lower  end  of  the  humerus  (Fig.  10.3),  and  has  pointed  out  the 
important  fact  that  the  outward  deflection  of  the  forearm  is  essential  to 
serve  for  tiie  purpose  of  the  "  I'arrving  function  "  (Fig.  KM).  The  reader 
is  referred  to  Dr.  Allis's  interesting  monograph  upon  this  subject.' 

The  signs  and  symptoms  of  fracture  of  the  external  condyle  are — 

'  Ann,  Anat.  and  Stirg.  Soc.  Brooklyn,  1880,  ii.,  289. 


.588 


FRACTURES. 
V\G.  103. 


Deformity  after  fracture  at  the  lower  end  of  the  humerus  (Allis). 

pain,  swelling  over  the  external  condyle,  the  presence  of  an  ill-defined 

tumor,  tenderness  upon  pressure,  crepitus  by  pronation  and  supination 

of  forearm,  and  sometimes  by  moving  fragment,  and 

Fig.  104.  finally,  inijiairnient  in  tiie  movement  of  the  joint. 

I  The  treatment  of  this  fracture  is  similar  to  that 

employed  in  fracture  of  the  internal  condyle,  so  tliat 

a  separate  description  is  unnecessary. 

Fracture  of  the  shaft  of  the  humerus  is  frequent- 
ly observed,  and  it  is  produced  by  direct  as  well  as 
by  indirect  violence,  and  even  by  muscular  action, 
and,  again,  bv  uterine  contraction.  It  has  been 
produced  during  the  act  of  parturition.  The  lower 
half  of  the  bone  is  more  frequently  broken  tiian  tlie 
upper  half,  and  the  line  of  fracture  is  generally 
oblique  from  al)ove  downward  and  outward.  A 
transverse  fracture  is  more  frequent  in  the  Inuiierus 
than  in  the  other  bones.  Fractures  involving  the 
shaft  include  all  below  the  surgical  neck  to  the  con- 
dyles of  the  bone. 

Tlie  displacement  in  fracture  of  the  siiaft  of  the 
humerus  largely  depends  upon  its  situation  in  refer- 
ence to  the  attaclnnent  of  tlie  deltoid  muscle.  If  aljove 
the  insertion  of  the  deltoid  and  below  the  insertion  of 
the  pectoralis  major,  hitissimus  dorsi,  and  teres  major, 
the  lower  fragment  is  found  to  lie  external  to  tlie  ujiper 
fragment  and  is  drawn  upward  by  the  deltoid  nuis- 
cle,  while  the  upper  fragment  is  drawn  inward  by  the 
action  of  the  pectoralis  major,  latissimus  dorsi,  and  teres 
major  muscles.  If  the  fracture  takes  place  below  the 
insertion  of  the  deltoid  muscle,  the  lower  fragment  is 
drawn  to  the  inner  side  of  the  upper  fragment  by 
the  action  of  the  triceps  and  biceps  muscles,  and  the 
The  outward  deflection  upper  frajrment  is  abducted  by  the  action  of  the  del- 

of    the    forearm— the    ,  '.',  i^,    ,,  ,.  -i  p  i    i       ii 

"carrying  function."    to  id,  and  at  the  same  time  drawn  torward  by  tlie  an- 


SrECFAL   FRACTURES. 


589 


terior  fibres  of  tlie  deltoid  and  the  pectoralis  major.  There  is  very  little 
displaeement  in  fractures  of  the  shaft  of  the  humerus  in  the  lower  j)art 
of  the  bone,  since  the  broad  insertion  of  the  brachialis  anticus  in  front 
is  counterbalanced  by  the  insertion  of  the  triceps  behind.  These  two 
muscles  so  completely  surround  the  shaft  of  the  humerus  that  little  or  no 
disj)lacement  occurs. 

The  signs  and  symptoms  of  fracture  of  the  shaft  of  the  humerus 
consist  of  pain  and  swelling,  with  eeehymosis  at  the  seat  of  frai'ture, 
crejiitus.  false  poiut  of  motion,  shortening  of  the  arm,  and  complete  loss 
of  function. 

The  treatment  of  fracture  of  the  shaft  of  the  humerus  depends  upon 
the  special  seat  of  the  fracture.  As  a  general  rule,  the  best  dressing,  if 
there  is  only  sligiit  displacement,  is  a  bandage  of  plaster  of  Paris  ajiplied 
over  a  layer  of  absorbent  cotton.  The  bandage  must  include  the  ticxetl 
forearm  as  well  as  the  arm,  and  then  form 
a  spica   over  the    shoulder.     In    ease   the  Fi<s- 106. 

fracture  is  attended  with  much  shortening, 
and  extension  seems  necessary,  the  short 
internal  an<l  the  long  external  splint  (Fig. 
105),  madi'  of  leather  or  gutta-percha  or 
pasteboard,  can  be  fitted  and  moulded  to 
the  opposite  arm,  and  then  adjusted  to  the 
broken  one.  Usually  the  weight  of  the 
arm  beloAv  the  fracture,  together  with  the 
forearm,  afford  sufficient  extension  when 
the  hand  is  swung  in  a  sling.  Great  care 
should  be  exercised  lest  the  internal  splint 
cause  compression  of  the  axillary  vessels. 


Fig.  105. 


I'liysirk'.s  i.lljiJK->|ili!]l, 


Clark's  extonsinn  in  fracture  of  the  neck 
of  the  hunieru.s. 


In  s])ecial  cases,  requiring  greater  extension  to  overcome  the  deformity 
and  to  maintain  the  ap]i(isiti(jn,  the  surgeon  can  employ  an  extension 
apparatus  by  means  of  adhesive  jilaster  applied  from  the  upper  end  of 
the  lower  fragment  to  the  elbow-joint,  and  from  the  cross-piece  below 
the  joint  attach  a  bag  of  sand,  as  suggested  by  Clark  (Fig.  106).  The 
patient  can  be  up  and  walk  about  during  the  repair  of  the  fracture,  or, 
if  for  any  reason  he  is  obliged  to  remain  in  bed,  a  weiglit  and  ]iullev  can 
be  used  as  in  fracture  of  the  tibia. 
rately  adjusted  to  the  existing 


The  weight,  however. 


]1Ul 

must  be  aeeii- 


conditious,  since  too  great  weight  might 


590 


FRACTURES. 


Fig.  107 


soj)arate  the  fragments  ami  cause  non-union  of  the  fractui-e,  a  not  uncom- 
mon complication  in  fractures  of  the  humerus.  Where  the  ui)])er  fnig- 
ment  .shows  a  tendency  to  hecome  al)ducte(l  with  a  slight  foi'wanl  incli- 
nation, a  splint  in  tiie  form  (if  a  triangle  has  been  suggested,  l)Ut  its 
emj)loyment  is  attendeil   witii  much  ditliculty. 

In  fractures  of  the  shaft  there  is  danger  of  non-unittn,  and  also  some 
danger  of  gangrene  of  the  fingers  from  too  tight  bandaging  or  from  too 
great  axillary  compi-ession  if  s})lints  or  pads  are  employed.  If  the  radial 
artery  cannot  be  felt  at  the  wrist,  no  bandage  or  splint  should  be  employed, 
since  its  application  migiit  be  considered  as  the  cause  of  gangrene. 
There  is  also  an  additional  danger  of  subsccjueiit  paralysis  of  the  mu.s- 

cles  presiding  over  supination  of  the 
forearm  and  extension  of  the  hand  and 
fingers,  causing  pronation  of  the  hand 
and  wrist-drop.  This  may  occur  as  a 
result  of  injury  to  the  nmsculo-spiral 
nerve  (Fig.  107),  or  in  conse(juence  of 
an  exuberant  callus  which  enslieaths 
and  compresses  the  nerve  (Fig.  108). 
In  the  latter  case  the  nerve  can  be 
tunnelled  out  after  the  fracture  is  re- 
paired (Fig.  109),  or  in  some  cases  the 
two  ends  of  the  divided  nerve  may 
be  found  and  sutured.  In  fractures 
of  the  humerus  Stromeyer's  cushion  (Fig.  110)  is  often  of  great  service 
if  for  any  reason  the  fracture  cannot  be  placed  permanently  in  a  retentive 
apparatus. 

Fractures  of  flir  Tapper  End  of  the  Hiimcrvs. — Epiphyseal  se]iaration  is 
usually  the  result  of  direct  violence,  as  a  fiill  or  blow  upon  the  shoulder. 
This  injury  is  not  observeil  after  tiie  twentieth  year  of  life. 

The  signs  and  symptoms  are  a  jirominence  below  tiie  coracoid  pro- 

TT      ,no  Fig.  109. 

Fig.  108. 


Paralysis  of  hand  (wrist-clrnp)  after  fracture 
of  liumerus. 


Permanent  flexure  from 
paralysis  after  fracture 
of  tlie  humerus. 


-->' 


Apparatus  for  wrist-drop  after  fracture  of  the 
humerus. 


cess,  due  to  the  upper  end  of  the  hiwcr  fragment,  whicli  ]iroiects  in  front 
of  the  shoulder-joint  ;  slight  crcjiitus,  which  is  obtained  l)y  mtatiim 
of  the  shaft  of  the  humerus  (Fig.  Ill) ;  the  alteration  in  the  axis  of  the 
shaft,  which  above  is  drawn  inward  by  the  action  of  the  anterior  jiectoral 
muscles,  and  is  directed  downward  and  slightly  backward  and  outward 
(Fig.  112) ;  the  head  of  the  bone  is  felt  in  the  glenoid  cavity,  but  does 
not  move  with  the  shaft  during  rotation  ;  ecchymosis,  tenderness,  and 
pain  are  well  marked. 

The  treatment  consists  in  making  extension  upon  the  shaft  of  the 
bone  until  the  projection  in  front  of  the  joint  disappears.     At  the  .same 


SPECIAL  FRACTURES. 


591 


time  the  tliumb  of  the  surgeon  shoukl  push  hack  tlie  u]ipcr  edge  of  the 
lower  fragment  into  its  proper  place.  The  elbow-joint  should  1)0  carried 
inward  to  the  side  of  the  tiiorax.     Compresses  and  pads  should  be  placed 


Fig.  no. 


Stromeyer's  axillary  cuf>liinn. 


over  the  front  of  the  joint,  and  they  should  be  held  in  place  by  a  felt 
shoulder-cap  or  a  leather  caj),  applied  wet  and  accurately  moulded  to  the 
sound   shoulder.     Care  should    be  exercised   lest  any    undue   pressure 


Fig. 111. 


Separation  of  the  upper  epiphysis  of  the  humerus  :  displacement  forward  of  the  lower  fragment. 


upon  the  front  of  the  joint  result  in  a  slough.  Some  slight  deformity 
may  exist  after  repair  of  this  injury,  but  the  movements  of  tlie  shoulder- 
joint  are  not  much  interfered  with,  since  the  separation  is  outside  of  the 
capsule. 


592 


FIIACTUBES. 


Fracture  of  the  tuberoftitj/  of  the  shaft  occurs  as  a  result  of  direct  vio- 
lence. The  iintero-posterior  diameter  of  tiie  joint  is  increased,  and  there 
is  a  sulcus  found  between  the  front  of  the  joint  and  the  fragment,  which 

Fi(^  112. 


/\ 


Separation  of  the  upper  epiphysis  of  the  humerus  (R.  W.  Smith). 


is  drawn  upward  and  abducted  by  the  external  rotators,  giviuw  tiic 
slioulder  a  peculiar  contour,  described  by  some  authors  as  trumpet- 
shaped,  on  account  of  the  double  tumor,  one  under  the  acromion,  and 
the  other  under  the  coracoid  process.  There  is  a  well-marked  depres- 
sion just  beneath  the  acromion  process,  and  crepitus  is  easily  obtained 
by  rotation  of  the  shaft  with  the  fingers  holding  the  sejiarated  tube- 
rosity. The  rotation  of  the  humerus  siiows  no  impairnuiit  in  the  move- 
ment of  the  head  of  the  bone  in  the  glenoid  cavity. 

The  treatment  of  fracture  of  the  tuberosity  consists  in  making  the 
.shaft  of  the  bone  adajjt  itself  to  tlie  detached  tuberosity.  This  is  best 
aeconi])lished  by  a  pad  in  the  axilla,  whicii  throws  the  ujtper  end  of  the 
bone  outward.  The  elbow  sluaild  be  l)rought  to  the  side  of  the  chest- 
wall  and  the  forearm  suspended  in  a  .«ling.  A  pad  should  lie  placed 
behind  and  above  the  tubercle  after  it  is  reduced,  so  as  to  prevent  it 
from  slipping  upward  and  backward  by  the  action  of  the  rotators 
attached  to  the  fi'agmcnt. 

Fracture  of  the  .surgical  ucck  is  situated  outside  of  the  capsule  of  the 
joint,  and  corresponds  to  the  extra-capsular  fracture  of  tlie  cervix  fenio- 
ris.  The  line  of  fracture  is  l)elow  the  tul)erosities,  but  above  the  inser- 
tion (Fig.  113)  of  the  pcctoralis  major,  latissimus  dorsi,  teres  major,  and 
deltoid  muscles. 


SPECLiL  FRACTURES. 


593 


Fig.  113. 


P'rat'ture  of  the  surgical  neck  of 
the  humerus. 


The  displacement  consists  of  an  external  rotation  and  abduction  of 
the  upper  fragment,  caused  by  tlie  action  of  the  muscles  inserted   into 
the  greater  tuberosity— viz.  tlie  supra-spinatus,  the  infra-spinatus,  and  the 
teres  minor  muscles — while  tlie  shaft  of  the 
bone  is  drawn  upward  into  the  a.xilla  by  tlie 
action   of  two   of  the   three  muscles  which 
take  tiieir  origin  from  the  coracoid  process 
— viz.    the   bice])s  and   the  coraco-bracliialis 
muscles — and  inward   by  the   action   (if  tlie 
peetoraiis  luajor  and  the  teres  nuij(ir  muscles. 

Tlie  signs  and  symptoms  are — absence 
of  rotation  of  the  head  of  the  bone  with  the 
shaft,  while  at  the  same  time  the  head  of  the 
bone  remains  in  the  glenoid  cavity  ;  shorten- 
ing of  the  arm  to  the  extent  of  al)out  one 
incli ;  crepitus,  unless  the  fracture  is  im- 
pacted;  swelling,  pain,  and  ecchymosis ;  al- 
teration in  the  a.xis  of  tiie  bone,  wliicii  is  di- 
rected downward  and  outward  ;  and  a  pecu- 
liar flattening  of  the  shoulder  just  Ijclow  the 
acromion.  This  flattening  is  not  so  marked 
as  ill  dislocation,  but  more  so  than  in  fracture 
of  the  anatomical  neck. 

The  treatment  consists  in  the  application 
of  a  plaster-of- Paris  bandage,  which  includes 
coaptation  splints  to  the  broken  arm  and  a  spica  over  the  shoulder, 
with  the  forearm  flexed  to  a  right  angle,  and  the  eiiiploynient  of  tlie 
axillary  pad.  In  case  the  fracture  is  attended  with  mucli  deformity,  a 
splint  in  tlie  form  of  a  triangle  lias  been  employed  with  great  success, 
since  the  apparatus  makes  the  shaft  adjust  itself  to  the  upper  fragment. 
If  it  is  unnecessary  to  employ  the  triangle,  the  elbow  should  be  carried 
well  forward  and  brought  close  to  the  side  of  the  body  ;  which  position 
has  a  tendency  to  overctime  the  inward  displacement  of  the  shaft. 

Fracture  of  the  anaioutiatl  ncch  is  produced  tiy  direct  violence,  as  in 
a  gunshot  wound  or  by  a  fall  upon  the  shoulder.  The  fracture  is  within 
the  capsule  of  the  joint,  and  corresponds  to  the  intra-capsular  fracture 
of  the  cervix  femoris.  The  fragment  receives  no  lilood-supply,and  is 
prone  to  undergo  necrosis  and  to  establish  sujijiuration  in  the  joint. 
Union  may  result  if  iiii]iaction  is  present,  and  for  this  reason  any 
attempt  roughly  to  niaiiipulate  the  fracture  with  a  view  to  a  diagnosis 
may  be  attended  with  serious  results. 

The  displacement  is  very  slight,  if  any,  owing  to  the  peculiar 
anatomical  conditions. 

The  signs  and  symptoms  consist  of  a  prominence  of  the  acromion 
and  flattening  of  tiie  shoulder,  both  of  wjiich,  liowever,  exist  only  to  a 
moderate  degree;  shortening  of  the  arm  to  the  extent  of  about  half  an 
inch,  with  pain,  swelling,  and  crepitus,  unless  the  fracture  is  impacted  ; 
and  absence  of  ecchymosis,  since  the  fracture  is  within  the  <-a])sule. 

The  treatment  consists  in  the  ajiplication  of  evaporating  lotions  for 
a  few  days  to  control  the  inflammation  in  tiie  joint,  and  afterward  in 
the  adjustment  of  a  felt  or  plaster-of-Paris  shoulder-cap  and  a  ])ad  in  the 

Vol.  I.— 3S 


594 


FRACTURES. 


axillii.  Groat  care  (should  be  exercised  lest  tlie  snrireon  break  up  tbe 
iinj)a(ti(iii   ami   thus  prevent  union  ol'  the  t'ra<;iiients. 

FiiACTUREs  OF  TiiK  FOKKAKM  may  bc  divided  into  fracture  of  the 
coronoid  or  olecranon  process  of  the  ulna,  of  tiie  shaft  of  the  ulna,  of 
the  styloid  process  of  the  ulna,  of  tlie  liead  and  neck  of  the  radius,  of 
the  shaft  of  the  radius,  of  the  lower  end  of  the  ra<lius  (Colles),  and  of 
both  radius  and  ulna. 

Fnicfnrca  of  the  nidius  and  ulna  usually  occur  as  the  result  of  direct, 
but  they  may  be  caused  by  indirect,  violence.  The  seat  of  the  fracture 
is  usually  about  the  centre  of  the  shaft  of  each  bone  (Fig.  114).  If  by 
direct  violence,  the  fracture  may  occur  at  any  place,  but  generally  at 


Fracture  in  the  middle  tliird. 


the  lower  end,  since  this  part  is  more  exposed  to  injury,  and  is  less  pro- 
tected bv  a  cushion  t)f  muscles. 

The  displacement  varies  according  to  the  situation  and  line  of  frac- 
ture. The  bones  may  be  so  displaced  as  to  form  an  angle  either  in  front 
or  behind,  or  even  laterally.  In  sfime  cases  the  fragments  overlap,  so  as 
to  cause  great  shortening  of  the  forearm. 

The  signs  and  symptoms  of  fractures  of  the  radius  and  ulna  are 
those  which  are  ordinarily  found  in  any  fracture,  such  as  crepitus,  loss 
of  function  of  limb,  great  jiain  and  tendernes.s,  unusual  mobility,  ecchy- 
mosis,  and  swelling. 

The  treatment  consists  in  reducing  the  fracture  by  the  surgeon 
making  extension  with  the  patient's  fingers  flexed  and  grasping  the  entire 
hand,  while  counter-extension  is  made  by  an  assistant,  who  seizes  the 
elbow-joint  while  the  forearm  is  flexed.  If  the  fracture  is  below  the 
insertion  of  the  pronator  radii  teres,  two  lateral  splints  should  bc  applied, 
and  the  forearm  placed  midway  between  pronation  and  supination.     The 

Fig.  11.5. 


Fusion  of  bones  after  fracture  of  radius,  destroying  pronation  and  supination. 

splints  should  be  wider  than  the  forearm,  so  that  the  bandage  or  strips  of 
adhesive  plaster  will  not  press  the  bones  together  and  cause  fusion  of  the 
bones,  which  ^\•oldd  destroy  the  function  of  pronation  and  supination 
(Fig.  115).     If  there  is  any  tendency  of  the  lower  fragments  to  drop,  the 


SPECIAL  FRACTURES. 


595 


lateral  splints  should  extend  below,  so  as  to  support  and  include  the 
hand.  If  the  fraoture  is  above  the  insertion  of  the  pronator  radii  teres, 
the  forearm  should  be  strongly  supinated  and  a  posterior  angular  sjilint 
applied  (Fig.  IK!). 

An  exeellent  metliod  of  treating  this  fracture,  if  the  individual  will 
submit,  is  for  the  patient  to  lie  in  bed,  and  then  to  extend  the  arm  and 

Fig.  116. 


IJr.  Scott's  splint  for  fracture  of  the  forearm. 

forearm  upon  a  long  flat,  firm  cushion.  This  position  brings  the  fragments 
into  accurate  ajiposition.  In  treating  any  fracture  of  the  forearm  in  the 
flexed  position  with  sitlints  great  care  must  be  exercised  lest  the  splints 
should  cause  undue  pressure  and  produce  gangi-ene  of  the  fingers.  The 
pressure  of  the  .splints  and  the  flexed  j)osition  of  the  forearm  necessarily 
retard  the  free  flow  of  blood  through  the  vessels,  and  for  this  reason  the 
possibility  of  gangrene  must  be  always  borne  in  mind. 

Fmdurr  of  fhc  lower  end  of  (lie  rdcliii.'^  is  known  as  Colles's  fracture, 
after  the  renowned  Irish  surgeon  who  first  described  the  nature  of  this 
injury.  The  seat  of  the  fracture  is  about  one  inch  above  the  articulation, 
at  the  junction  of  the  compact  with  the  cancellated  bony  tissue.  This 
fracture  has  also  been  called  the  "silver-fork  fracture,"  because  the 
characteristic  deformity  reseml)les  the  slia]ie  of  an  ordinary  silver  fi>rk. 
Tiie  dorsal  proniiuence  is  due  to  the  riding  ujiward  and  l)ackward  of  the 
lower  fragment  witli  tlie  carpus,  while  tjie  palmar  deformitv  is  produced 
by  a  projection  forward  of  tiie  lower  end  of  the  upper  fragment,  which  is 
pronated  by  the  action  of  the  pronator  quadratus  and  pronator  radii  teres 
muscles.  The  internal  lateral  ligament  is  generally  torn  out  of  its  inser- 
tion into  the  styloid  process,  and  Moore  has  demonstrated  tliat  the  process 
becomes  entangled  in  theanuidar  ligament.  Tlic  lower  end  of  the  up]>er 
fragment  is  generally  driven  into  the  upper  end  of  the  lower  fragment 
by  the  continuance  of  the  same  force  that  originally  caused  the  fracture. 
This  impaction  of  the  upper  fragment,  consisting  of  compact  bony  tissue, 
into  the  lower  fragment,  formed  of  cancellated  tissue,  explains  the  frequent 
absence  of  crepitus  in  the  fracture  (Fig.  1 17). 

The  signs  and  symptoms  of  fracture  of  the  lower  end  of  the  radius 
are — inability  to  sup])ort  the  firearm,  the  position  of  the  hand  midway 


596 


FR A  ('TUBES. 


between  pronation  and  su|iiiiatii)ii,  the  flcxidii  of  (lie  fingers,  the  silver- 
fork  deformity,  tlic  great  |)r(»iiiiiK'nce  of  the  styloid   process  of  tiie  uhui, 


Fig.  117 


CoUes's  fracture:  union  with  persistence  of  displacement  (Smith). 

the  loss  of  snpination  and  pronation,  severe  pain,  and  often  swelling  due 
to  eifusion  into  the  sheaths  of  the  tendon. 

The  treatment  of  this  fracture  consists  in  overcoming  at  once  the 
deformity  hy  prom])tly  reducing  the  fracture  and  tiien  retaining  the 
fragments  immovably  fixed  in  tlieir  proper  j)ositiou.  The  reduction  is 
made  by  the  surgeon  grasping  the  hand  of  the  patient  as  if  to  shake 
hands  with  him,  and  tlien  making  forcible  continut)us  and  gradual 
extension,  so  as  to  disengage  the  impaction  and  bring  the  lower  frag- 
ment into  apposition  with  the  upper.  The  surgeon  should  place  the 
thumb  of  the  left  hand  against  tlic  styloid  process  of  the  ulna  and  push 
it  around,  so  as  to  bring  it  into  its  normal  ])osition.  In  some  cases  it 
may  be  necessary  to  administer  an  ana'.sthetic  in  order  to  reduce  sati.s- 
factorily  the  deformity.  The  fixation  of  the  adjusted  fragments  can  be 
maintained  by  several   dift'erent  forms  of  splints. 

The  best  dressing  is  by  two  lateral  splints,  which  should  be  well 
padded  and  broad,  and  extend  from  the  extreme  u]iper  end  of  the  fore- 
arm to  exactly  the  lower  margin  of  the  lower  fragment,  and  leave  the 
wrist-joint  free.  The  forearm  should  then  Ix-  placed  in  a  sling,  so  that 
the  hand  falls  downward  and  is  adducted  by  its  own  \veight,  in  M'hicli 


Fin  lis. 


Gordon's  splint  for  fracture  of  the  lower  end  of  the  radius  :  B,  the  palmar  splint ;  C,  the  dorsal 
splint ;  A,  the  two  splints  applied  to  the  forearm. 

position  the  torn  ligament  from  the  styloid  fossa  is  relaxed  and  the  frag- 
ment of  the  radius  is  brought  into  accurate  apposition.     This  freedom 


SPECIAL  FRACTURES. 


597 


of  motion  of  the  wrist -joint  docs  not  interfere  with  the  complete  fixation 
of  the  fragments,  and  prevents  ankylosis  of  the  joint,  as  well  as  any  snb- 
seqnent  rigitlity  of  the  fingers. 

Gordon's  apparatns  consists  of  two  pieces,  a  palmar  splint  (Fig.  118) 
constructed  so  as  to  overcome  the  forward  displacement  of  the  fragment 
bv  the  addition  of  a  conical  piece,  whicii  produces  jiressure  upon  the 
lower  end  of  the  ujiper  fragment,  and  thus  has  a  tendency  to  elevate 
it,  while  the  hand  itself  raises  the  lower  fragment.  The  other  splint  is 
applied  to  the  dorsal  surface  of  the  ftirearm,  and  by  its  thick  padding 
over  the  wrist  has  a  tendency  to  overcome  the  deformity. 

Carr's  apjiaratus  (Fig.  119)  consists  of  a  palmar  splint  padded  so  as 
to  obliterate  the  depression  over  the  radius.     To  the  extremity  of  this 

Fm.  119. 


Carr's  spliut  for  a  loft  CuUes  fracture. 


palmar  splint  is  attached  an  oblique  vertical  piece,  and  on  this  round  bar 
the  fingers  are  flexed.  This  palmar  spliut  is  supplemented  by  a  second 
or  dorsal  splint. 

Bond's  apparatus  (Fig.  120)  consists  of  a  splint  made  of  a  piece  of 
wood,  to  the  lower  extremity  of  which  is  fixed  a  curved  block  which 


Fig.  120. 


Bond's  splint. 


should  fit  the  hollow  of  the  palm  in  order  to  give  support  to  tiie  hand 
and  fingers.  The  splint  should  be  well  jiadded,  so  as  to  fill  up  the  con- 
vexity of  the  radius  on  its  palmar  side.  In  conjunction  with  the  palmar 
splint  a  dor.sal  splint  is  used,  with  a  compress  so  adjusted  as  to  etl'ect  the 
reduction  of  the  lower  fragment. 

A  fracture  consisting  of  a  chipping  off  of  the  posterior  liji  of  the 
articulating  surface  of  the  radius  has  IjCen  described  by  Barton,  after 
whom  the  fracture  is  named.  The  fracture  clinically  requires  the  same 
treatment  as  that  indicated  for  Colles's  fracture. 

Fracture  of  flic  xhaft  of  the  radinH  occurs  by  direct  violence,  as  a 
blow  upon  the  forearm,  or  by  indirect  violence,  as  a  fall  u])on  the  hand. 
As  a  rule,  however,  a  fracture  of  the  radius  caused  by  a  fall  upon  the 


rm 


FRACTURES. 


Fracture  of  the  radius 


liaiid  is  situated  in  tlic  lower  end,  Imt  occasionally  this  injury  causes 
a   tVaetiire  of  the  shaft  of  the  hone. 

The  displacement  in  fractures  of  tiie  shaft  depends  u]ion  the  situation 
of  the  fracture,  since  the  deforniity  varies  accordinti;  to  wlicther  the  frac- 
ture is  above  or  below  the  insertion  of  the  pronator  radii  teres  muscle. 
If  the  fracture  is  above  the  insertion  of  this  muscle  and  below  that  of 
the  biceps,  the  upper  fragment  is  strong'ly  supinated  and  flexed,  while 
the  lower  frafi-ment  is  ]ironated  Ity  the  pronator  radii  teres  and  the  pro- 
nator (juadratns.  Tliis  displacement  is  not  very  ap])arent,  on  account  of 
tile  anatomical  conditions;  but  if  union  takes  place  without  correcting 
the  deformity,  fusion  of  the  bones  occurs  and  the  movements  of  prona- 
tion and  supination  are  lost ;  and  this  movement  can  only  partially  be 
accomplished  by  the  shoulder.     If  the  fracture  is  situated  below  the 

insertion  of  the  pronator  radii 
F'f--  121.  teres,  this  muscle  oj)poses  the 

action  of  the  biceps  ;ind  the 
supinator  brevis,  so  that  the 
forearm  remains  in  a  position 
midway  between  pronation  and 
supination  (Fig.  121).  The 
supinator  longus  below  o])poses 
the  feeble  action  of  the  ])rona- 
tiir  ((uadratus.  Tlie  disjdacc- 
ment  consists  of  slight  flexion 
of  the  upper  fragment  by  the 
biceps  and  pronation  by  the 
pronator  radii  teres,  and  a  drawing  inward  of  the  lower  fragment  by  the 
pronator  (piadratus,  assisted  l)y  the  supinator  longus,  which  by  traction 
of  the  lower  end  of  the  lower  fragment  tilts  the  upper  end  of  the  lower 
fragment  toward  the  ulna. 

The  signs  and  symptoms  of  fracture  of  the  shaft  of  the  radius  are 
those  usually  found  in  any  fracture,  such  as  pain;  talse  point  of  motion; 
and  crepitus,  which  in  this  special  fracture  is  elicited  by  rotating  the 
hand  while  the  surgeon  places  his  thumb  on  the  head  of  the  radius, 
or  by   indentation  of  the  two  broken  ends  at  the  seat  of  fractiu'c. 

The  treatment  varies  according  to  the  seat  of  the  fracture.  From  a 
careful  study  of  the  dis])lacement  when  the  fracture  is  above  the  inser- 
tion of  the  pronator  radii  teres,  it  is  evident  that  the  forearm  must  be 
strongly  supinated  in  order  to  bring  the  fragments  into  accurate  apposi- 
tion. For  this  purpose  it  is  necessary  strongly  to  supinatc  the  forearm. 
Tills  can  be  done  by  placing  tiie  jwticnt  in  bed  and  stretching  his  arm 
out  at  a  right  angle  from  the  trunk,  and  allowing  the  supinated  arm  to 
rest  upon  a  hard  cushion ;  or,  if  the  patient  is  unwilling  to  be  confined 
to  the  bed,  the  forearm  can  be  flexed  to  a  right  angle  with  the  arm,  and 
a  splint  applied  to  the  arm  and  forearm  (Fig.  122),  so  that  the  palm  is 
directed  upward.  If  the  fracture  is  below  the  insertion  of  the  pronator 
radii  teres,  tlie  application  of  two  lateral  splints  can  be  made,  with  the 
forearm  midway  between  pronation  and  supination.  Some  surgeons 
recommend  that  the  sjilint  extend  only  to  the  wrist-joint,  but  if  there  is 
much  mobility  it  may  be  well  to  have  the  splint  extend  below  and  sup- 
port the  hand,  since  there  is  no  tendency  for  the  wrist-joint  to  become 


SPECIAL  FRACTURES. 


599 


ankylosed.     A  small  strip  or  pad  down  the  centre  of  the  splint  has  been 
suggested,  so  as  to  separate  the  radius  and  ulna  to  prevent  au}-  union 


Fig.  122. 


Dr.  Scott's  spliut  for  fracture  of  the  forcani 


Fig.  123. 


of  the  two  bones,  which  would  imjiair  the  movements  of  2>ronation  and 
supination. 

Fntcfurc  of  the  hnifl  (uifJ  neck  of  the  nifliiix  I'arely  occurs,  except 
in  connection  with  a  dislocation  backward  of  both  bones  of  the  forearm 
or  witli  a  fractiu'c  of  the  coronoid  process  of  the 
ulna.  The  fracture  may  be,  however,  occasionally 
observed  as  the  result  of  a  gunshot  injury,  or  it  may 
be  jirescnt  in  the  form  of  a  compound  fracture,  in 
M-hich  ca.se  the  head  and  neck  are  usually  sijlintercd 
in  the  long  axis  of  the  bone  (Fig.  123).  It  is  some- 
times found  to  be  comminuted. 

The  signs  and  symptoms  are  inability  to  pro- 
nate  or  supinate  the  forearm  ;  crcj)itus  at  the  .seat 
of  fracture,  elicited  by  seizing  the  patient's  hand 
and  proiiating  the  forearm  while  the  thiiml)  of 
the  surgeon's  otlier  hand  is  placed  over  the  orbic- 
ular ligament;  the  presence  of  an  unnatural  bony 
prominence  at  the  in.sertion  of  the  biceps,  due 
to  the  Hexion  and  supination  of  the  fragment  by 
the  action  of  this  muscle ;  the  presence  of  ecchy- 
mosis  and  localized  pain  ;  and  the  jieculiar  position  Fracture  of  neck  of  rajius. 
of  the  forearm,  wliich  is  pronated. 

The  treatment  consists  in  placing  the  forearm  in  a  position  of 
extreme  flexion,  which  relaxes  the  biceps,  which  tilts  forward  the  frag- 
ment. A  compress  should  be  applied  to  the  fragment  in  order  to 
keep  it  in  position,  and  the  limb  bandaged  to  an  angular  s])lint.  Care 
must  be  taken  not  to  produce  any  compression  upon  the  brachial 
artery  while  the  forearm  is  extremely  flexed,  lest  the  circulation  be 
disturbed  and  gangrene  ensue.  Passive  motion  must  not  be  practised 
until  the  fragment  is  well  united,  lest  the  biceps,  contracting  during 
forced  extension,  might  separate  the  fragment.     If  there  is  great  tend- 


600  FRACTURES. 

ency  for  the  fragment  to  become  flexed  and  supinated  by  a  rigid  con- 
traction of  the  biceps,  tenotomy  will  iniincdiately  overcome  the  deform- 
ity, and  the  parts  will  be  at  once  adjusted. 

FracUiir  of  tli<'  sti/loid  jtronns  of  the  iiliKt  occurs  as  a  result  of  direct 
violence.     The  fragment  is  distinelly  felt  just  beneath  the  skin. 

The  signs  and  symptoms  are  too  a])parent  to  require  any  special 
description.  The  broken  fragment  should  be  manipulated  until  it  is 
brought  into  its  proper  position,  and  then  maintained  there  by  the  use 
of  a  compress  which  is  held  firmly  in  n'tiu  by  strips  of  rublx'r  jilaster. 
It  is  advisable  to  keep  tiie  wrist-  and  elbow-joints  at  rest  for  a  short 
time  until  the  fragment  tmites,  as  any  movement  of  these  joints  has 
a  tendency  to  displace  the  broken  part. 

Fracture  of  the  shaft  of  the  ulna  occurs  as  a  result  of  a  fall,  or  in 
boxing,  in  warding  f)ff  blows  aimed  at  the  face,  and  its  seat  is  usually 
just  below  the  midille  of  the  bone,  since  at  this  point  the  bone  is  not  so 
thick  and  is  less  protected  by  a  cushion  of  muscles. 

The  displacement  is  caused  by  the  action  of  two  muscles — viz.  the 
brachialis  anticus,  wliich  has  a  tendency  to  flex  the  upjier  fragment, 
and  the  pronator  quadratus,  which  has  a  tendency  to  abduct  it  and 
thus  draw  it  toward  the  radius. 

The  signs  and  symptoms  are  localized  pain,  tenderness,  and  ecchy- 
mosis,  the  presence  of  a  tumor,  the  existence  of  crepitus  and  great  mobil- 
ity. The  finger,  if  passed  along  the  sliaft  of  the  Ixme,  will  usually  detect 
the  fracture,  as  the  bone  is  quite  superficial  in  the  lower  half  of  the 
shaft. 

The  treatment  consists  in  the  application  of  two  broad  lateral 
.splints  from  the  ell)ow-  to  the  wrist-joint.  Before  adjusting  the  splints 
the  broken  ulna  should  1)(>  forced  away  from  the  radius,  so  as  to  jtrevent 
any  fusion  of  the  bones  of  the  forearm,  which  would  impair  pronation  and 
supination.  The  forearm  should  be  flexed  at  a  right  angle  in  order  to 
relax  the  brachialis  anticus,  which  has  a  tendency  to  tilt  forward  the 
upper  fragment,  and  also  be  placed  midway  between  pronation  and 
supination.  The  forearm  sliould  be  carried  in  a  sling,  and  the  lateral 
splints  should  be  broad  enough  to  prevent  any  pressure  upon  the  broken 
bone,  which  pressure  would  have  a  tendency  to  cause  fusion  of  the  two 
bones  of  the  forearm. 

Fracture  of  the  coronoid  and  olecranon  processes  of  the  ulna  occurs  as 
a  result  of  a  fall  upon  the  back  of  the  elbow  during  semi-flexion  of  the 
forearm,  or  by  muscular  action.  Fracture  of  either  process  is  seldom 
seen  in  a  person  under  fifteen  years  of  age. 

Fracture  of  the  coronoid  process  usually  occurs  as  a  comjilication  in 
backward  dislocation  of  both  bones  of  the  forearm,  whicli  acciilcnt  is 
usually  the  result  of  a  fall  upon  the  palm  with  the  elbow-joint  partially 
flexed.  The  fracture  has  been  observed  as  a  result  of  muscular  action 
in  attempts  to  lift  the  weight  of  the  body  with  the  hand  or  in  grasping 
by  the  hands  an  object  in  the  act  of  falling  from  a  height. 

The  sig-ns  and  symptoms  are  backward  dislocation  of  botli  bones 
of  the  forearm,  the  presence  of  crepitus,  the  existence  of  a  bony  prom- 
inence in  the  transverse  fold  of  the  elbow-joint,  and  a  tendency  to  return 
of  the  deformity  after  reduction. 

The  treatment  consists  in   placing  the   forearm  in  an  extremely 


SPECIAL  FRACTURES.  601 

flexed  position  to  relax  the  brachiali.s  antieus  muscle,  and  applying  an 
angular  splint  with  an  aligle  adapted  to  the  position.  II'  the  fragment 
persists  in  becoming  displaced,  it  can  be  wired  to  the  shaft.  In  such  au 
operation  the  close  proximity  of  the  brachial  artery  must  not  be  over- 
looked. Unless  the  fragment  is  sutured,  the  union  is  likely  to  be  liga- 
mentous, and  passive  motion  should  bo  instituted  after  three  weeks  iu 
order  to  preserve  the  mobility  of  the  joint. 

Fracture  of  the  olecranon  jyrocess  of  the  ulna  occurs  during  adult  life 
iind  seldom  before  the  fifteenth  year.  The  fracture  is  the  result  of 
direct  violence,  either  from  a  blow  upon  the  process  or  by  a  fall  upon  the 
part  when  the  elbow-joint  is  flexed  to  a  riglit  angle.  This  fracture  also 
occurs  by  muscular  action,  as  in  sudden  I'ontraction  of  tlie  triceps  dur- 
ing extension  of  the  forearm.  The  mechanism  of  fracture  by  this  cause 
is  tliat  of  a  lever  across  the  condyles  t)f  the  humerus. 

The  signs  and  symptoms  are — well-marked  depression  at  the  back 
of  the  elliow-joint,  produced  by  the  action  of  the  triceps  in  drawing 
upward  tiie  fragment ;  the  presence  of  crepitus,  elicited  by  flexing  and 
extending  the  forearm  ;  abnormal  mobility  of  the  fragment;  tiie  exist- 
ence of  synovitis  of  the  elbow-joint ;  the  stationary  appearance  of  the 
fragments  ;  and  the  separation  of  the  shaft  of  the  ulna  from  it  during 
extension. 

The  treatment  consists  in  placing  a  compress  over  the  fragment 
after  it  has  been  reduced,  and  applying  a  strip  of  adhesive  plaster  to 
keep  the  fragment  innnovaljly  fixed  to  the  shaft  of  tlie  ulna.  A  straight 
splint  which  is  M-ell  padded  should  now  be  adjusted  to  the  arm  and 
forearm  upon  their  anterior  surface,  with  the  limb  in  an  extended 
position.  If  the  fragment  cannot  be  kept  iu  place,  sutui"iug  it  to  the 
shaft  is  indicated.  This  operation  must  be  done  with  every  aseptic  pre- 
caution, since  the  wound  conununicates  with  the  joint.  If  the  fracture 
is  compound,  suturing  is  indicated,  and  at  the  same  time  free  drainage 
of  the  joint  for  a  few  days  must  be  employed.  If  for  special  reasons 
suturing  is  not  advisable  and  a  stiff  joint  is  likely  to  ensue,  the  fore- 
arm should  be  placed  midway  between  flexion  and  extension,  since  this 
position  renders  the  upper  extremity  more  serviceable  than  the  straight 
position,  whicli  gives  the  patient  practically  a  useless  arm. 

Fracture  of  the  carpal  bones  is  rare,  and  occurs,  as  a  rule, 
from  direct  violence.  Owing  to  the  strong  ligaments  which  hold  the 
carpal  bones  together,  there  is  little  displacement.  Fractures  of  these 
bones  are  often  overlooked  on  account  of  the  extensive  damage  of  tlie 
soft  parts  and  the  consequent  swelling  of  the  wrist-joint.  There  is 
very  little  dis])lacement,  owing  to  the  anatomical  arrangement  of  the 
wrist  articulation. 

Tlie  sig-ns  and  symptoms  are  crepitus,  swelling,  pain,  and  loss  of 
function  of  the  joint. 

The  treatment  consists  in  placing  the  hand  upon  a  long  palmar 
splint,  at  the  smne  time  ajiplying  over  the  injured  part  warm  fomenta- 
tions or  cold  evaporating  lotions  until  the  acute  inflammation  has  sul)- 
sided.  In  severe  contusion  of  tlic  soft  parts  without  wound  the  warm 
applications  are  best  suited,  wliile  iu  severe  inflammatory  reaction  unac- 
companied by  external  wound  the  cold  lotion  is  indicated.  Absolute 
rest,  a  moderate  amount  of  compression,  and  an  immovable  splint  to  give 


602  FRACTURES. 

support  to  the  liantl,  \vi"ist,  and  ibroarm  are  required.  \\'hen  tlie  signs 
of  acute  inflaiiiniation  have  di.sapj)eared,  a  splint  shouhl  he  a])iilied,  and 
passive  motion  bcnuu  after  a  fortniglit  in  order  to  preserve  the  motion 
of  the  joint.  If  the  fraeture  is  ('ompound,  the  loose  fragment  must  bo 
removed,  the  joint  thoroughly  irrigated,  and  a  drainage-tube  passed 
through  from  the  dorsal  to  the  j)almar  surface,  and  antise})tic  dressing.s 
applied  together  with  a  splint. 

Firictures  of  the  iiwtacarjMtl  honefs  are  common,  and  are  usually  the 
result  of  direct  violence.  On  account  of  tiie  exposed  jxisition  of  the 
first  metacarpal  bone,  it  is  found  to  l)e  tiie  one  most  fre(piently  fractured, 
and  after  it,  next  in  point  of  frequency,  the  second,  \vhilc  the  third  is 
less  frequently  broken  than  the  others.  The  ujjper  fragment  is  usually 
disjilaced  downward  toward  the  ])alm  of  the  hand,  owing  to  the  action 
of  the  interosseous  muscle  and  the  natural  shape  of  the  shaft  of  the 
bone. 

The  signs  and  symptoms  consist  of  crepitus,  pain,  swelling,  inter- 
ruption of  the  continuity  of  the  shaft  of  the  bone,  prominence  in  the 
palm  of  the  hand  due  to  the  presence  of  the  distal  end  of  the  proximal 
fragment,  the  dropjiing  of  tlie  knuckle,  and  the  depression  on  the  dorsum 
due  to  tlie  falling  down  of  the  two  fragments. 

Tlie  treatment  consists  in  jilacing  tiie  hand  upon  a  long  palmar 
splint  extending  from  the  elbow  to  a  point  biyond  the  tingers,  with  a 
pad  over  the  seat  of  fracture  on  the  palmar  surface  of  the  hand,  or  by 
flexing  tlie  hand  over  a  ball,  so  as  to  push  up  the  displaced  fragments  by 
mechanical  action  and  by  extension  of  the  fragments,  and  at  the  same 
time  ap])lying  the  long  splint. 

Too  much  importance  cannot  be  attached  to  the  conservative  treat- 
ment of  compound  fractures  of  these  bones.  The  parts  are  so  vascular, 
and  the  retluction  of  the  fragments  so  easy,  that  it  seldom  becomes 
necessary  to  perform  amputation  if  proper  antiseptic  precautions  are 
emploved.  The  fragments  should  be  wired  if  greatly  displaced,  or 
some  of  the  connninuted  pieces  should  be  removed  and  the  periosteum 
left,  or  even  transplantation  of  the  bones  can  be  accomplished  when 
the  necessary  conditions  are  present.  In  Figure  124  is  shown  the 
result  obtained  in  a  case  of  a  compound,  conmiinuted,  and  complicated 
fracture  of  the  second  metacarpal  bone  and  the  two  phalanges  of  the 
thumb.  As  the  two  phalanges  of  the  thumb  were  spontaneously  ampu- 
tated l)y  machinery  at  the  time  of  the  acci<lent,  the  metacarjial  bone 
of  the  thumb,  whicli  was  not  injured,  was  transplanted  and  attached  to 
the  proximal  end  of  the  first  |)lialanx  of  the  index  finger,  which  was  also 
uninjured.  The  metacarpal  bone  belonging  to  that  finger  was  conmii- 
nuted, and  its  pieces  forced  out  of  the  hand,  so  that  its  place  was  now 
occupied  by  the  first  metacarpal  bone  of  the  thumb.  The  result  of  the 
operation  was  most  gratifying,  since  the  patient  had  a  most  useful  hand, 
which  was  sujierior  to  any  artificial  one.  The  ojieration  was  performed 
in  my  hospital  service  by  Dr.  Ran,  the  house-surgeon. 

Avulsion  of  the  phalanges  requires  consideration.  This  accident 
occurs  where  the  finger  is  held  in  a  door  of  a  stage  or  car,  or  where  the 
finger  is  caught  upon  some  object  while  the  patient  is  running.  The 
entire  jilialanx  is  torn  away  from  its  nearest  articulation,  and  with  it  the 
tendon  of  the  muscle  which  is  inserted  into  it.     Avulsion  of  the  thumb. 


DISLOCATIONS. 


603 


with  tlie  tendon  of  tlie  flexor  lonsus  pollicis,  has  oocnrivd  in  violent 
attempts  to  reduce  a  ilisloeation  of  the  thumb,  a  beautiful  example  of 

Fk;.  1-24. 


Amputation  f>f  first  and  second  phalanges  of  the  thuml),  and  excision  of  the  metacarpal  bone  of 
index  linger;  transplantation  (jf  metacarpal  bone  of  the  thumb  to  the  index  linger. 

which,  as  well  as  of  similar  results  from  other  causes,  is  seen  in  the 
accompanying  plate  (Fig.  12">). 

The  treatment  of  simple  fractures  of  the  phalanx  consists  in  restor- 
ing the  fragments  to  their  proper  place  and  holding  them  in  sift}  by 
means  of  a  gntta-jtercha,  jxisteboard,  metal,  or  leather  splint,  accurately 
moulded  to  the  corresponding  finger  of  the  opposite  hand,  and  then 
aj)plied  to  the  injured  and  extended  phalanx.  In  addition  to  a  s])lint 
directly  applied  to  the  fractured  part,  a  long  splint  should  extend  from 
the  palm  of  the  hand  to  the  tip  of  the  linger,  so  as  to  keep  the  frag- 
ments inmiovaljly  <piict  during  the  repair  of  the  fracture.  If  the  frac- 
ture is  compound  and  comminuted,  the  surgeon  should  endeavor  to  save 
as  much  as  possil)le,  and  remove  only  j)ieces  which  are  detached  from 
the  periosteum,  since  the  reparative  process  is  so  great  that  a  fracture  in 
this  i)art  would  repair  where  elsewhere  the  bone  might  undergo  necrosis. 

Fracture  of  the  phalanges  occurs  as  a  result  of  direct  violence,  and 
on  account  of  the  exposed  position  of  the  hand  is  frequently  observed. 
The  important  fact  must  always  be  borne  in  mind  that  while  an  artificial 
limb  can  be  substituted  fi)r  the  arm  or  forearm,  the  leg  or  thigh,  no 
prosthetic  apparatus  has  been  devised  to  take  tlie  ])lace  of  tiic  finger. 
For  this  reason  it  is  imperative  for  the  surgeon  to  apply  the  principles  of 
extreme  conservatism  in  the  management  of  fractures  of  the  phalanges, 
and  in  carrying  out  this  principle  too  much  importance  cannot  be  jilacecl 
on  the  great  vascularity  of  the  parts  and  their  tendency  to  heal  even  after 
the  most  extensive  iniurv. 


Dislocations. 

A  dislocation  is  a  solution  in  the  contiguity  of  bones,  and  is  in  con- 
trast to  a  fracture,  which  is  a  solution  in  the  continuity  of  a  bone.  A 
diastasis  is  where  the  bones  are  separated  from  each  other,  as  when 
the  pubic  bones  separate  at  the  symphysis  pubis.     The  term  "  disloca- 


604 


FRACTURES. 
Fig.  125. 


Specimens  showing  avulsion  of  tlie  distal  phalanges  in  attempts  to  reduce  a  dislocation  of  the 
thumb,  the  result  of  an  accident. 


DISLOCATIOXS. 


605 


tion"  is  derived  from  the  Latin  preposition  r/w,  meaning  a  separation, 
and  the  noun  locus,  denoting  a  phiee. 

Disloeations  are  less  frequent  than  fractures  in  ahout  tlie  proportion 
of  1  to  8.  A  simple  dislocation  is  one  in  which  the  joint  is  displaced 
without  concomitant  injury  to  vessels,  nerves,  or  bones.  A  compound 
dislocation  occurs  when  the  displacement  is  of  such  a  character  as  to 
open  the  joint  and  expose  it  to  the  external  air.  A  dislocation  is  com- 
plicafed  when  the  dis])lacement  is  associated  with  a  laceration  of  the 
vessels  or  nerves  or  a  fracture  coexists.  A  compldc  dislocation  is  one  in 
wiiich  the  joint-surfaces  are  entirely  se]iaratcd.  An  iiirtniiplrtc  disloca- 
tion is  one  in  which  the  joint-surfaces  are  only  partially  separated.  From 
a  study  of  Gurlt's,  Kronlein's,  and  Prahl's  tables  it  is  demonstrated  that 
dislocations  of  the  upper  extremity  form  nearly  three-fourths  of  all  dis- 
locations, that  the  shoulder  is  the  most  fre(piently  dislocated  joint  in  the 
body,  and  the  ell)ow  next,  while  in  the  remaining  one-fourth  dislocations 
of  the  fingers  ami  the  hip  are  in  tile  majority.  In  regard  to  sex,  it  is 
also  proven  that  dislocations  are  three  times  more  frequent  in  males, 
with  the  exception  of  the  jaw,  where  the  proportion    is    more    than 


Fig,  126. 


Fig.  127. 


Congenital  dislocation  of  hip. 


reversed.     As  regards  age,  it  is  demonstrated  that  between  the  ages 
of  fifty  and  sixty  dislocations  are  most  frequent,  and  that  dislocations 


606 


DISLOCATIONS. 


Fia.  128. 


are  less  fro(|tient  (luring  tlio  years  wlicii   fractures  are  most  common, 
especially  during  infancy  and  youth. 

There  are  three  distinct  varieties  of  dislocations — tiie  congenital,  the 
jjdfliolof/iral,  and   the  traumatic. 

A  cdiii/ciiitfi/  dislocation  is  one  in  wliich  tlic  joiiil-surfaces  do  not  fit, 
owing  to  arrest  of  dcveloptncnt  in  tiic  fcetus  or  to  some  nialfurinatiun 
of  the  parts,  as  in  tiie  different  varieties  of  club-foot,  torticollis,  or 
s])inal  curvature.  This  variety  occurs  in  87  per  cent,  of  the  cases  in 
females,  and  affects  generally  the  hip-joint  (Fig.  126).  It  may  also 
occur  as  a  result  of  abnormal  uterine  contraction,  or  of  fiills  upon  the 
abdomen  during  jiregnancy,  or  of  some  violence  during  obst(>trical 
manipulation  in  a  case  of  ditiicult  labor.  Congenital  dislocation  may 
also  result  from  disturbance  of  the  nervous  centres,  as  in  spastic 
contractions  of  the  muscles,  in  infantile  paralysis,  and  in  pseudo-hyper- 
trophy. A  congenital  dislocation  is  not  always  recognized  at  the  time 
of  l)irth,  and  often  not  until  the  child  makes  attempts  to  walk.  The 
hi]),  shoulder,  knee,  ankle,  patella,  tarsus,  and  phalanges  are  among  the 
joints  and  bones  that  are  most  frequently  the  seat  t)f  this  special  variety 
of  dislocation. 

The  pathological  dislocation,  as  its  name  implies,  is  one  produced  as 
the  result  of  (lisease.  This  variety  is  seen  during  the  progress  of 
morbus  coxarius,  and  also  in  chronic  disease  of  the  knee-,  ankle-,  and 
other  joints.     The  joint  disease  produces  absorption  of  the  head  of  the 

bone  with  destruction  of  the  capsule, 
and  the  entire  cavity  and  the  head  of 
tile  bone  become  more  or  less  oblit- 
erated (Fig.  128).  Another  variety 
niav  occur  as  a  result  of  reflex  muscu- 
lar contraction  from  disease  of  the  spi- 
nal cord,  and  in  tiiis  variety  a  distinc- 
tion must  be  made  from  the  preceding 
|iatliological  dislocation,  since  tlie  joint 
itself  is  not  the  seat  of  bone  disease. 
This  same  variety  may  also  occur  in  the 
course  of  certain  fevers,  as  typhoid, 
or  articular  rheumatism  :  suddenly  the 
joint,  usually  the  hip,  Ijccomcs  dislo- 
cated, the  ca])sule  having  ruptured 
from  over-distention. 

The  traumatic  dislocation,  which 
is  due  to  external  violence,  may  oc- 
cur in  almost  any  joint  in  the  body. 
The  injury  may  result  in  either  a 
complete  or  an  incomplete  luxation 
of  the  joint,  the  special  form  of  which  depends  upon  the  amount  of  vio- 
lence exercised,  together  with  the  peculiar  anatomical  conformation  of 
the  joint.  Kronlein  has  demonstrated  that  about  90  per  cent,  of  the 
traumatic  dislocations  affect  the  upper  exti-emity,  while  only  about  5  per 
cent,  involve  the  lower  extremity,  and  the  remaining  affect  the  trunk. 
The  ages  between  twenty  and  forty  are  the  periods  when  traumatic  dis- 
locations are  most  frequently  observed. 


Pathological  dislocation  of  the  hip-joint. 


DISL  0  CA  TIOKS.  60  7 

Tlie  pathology  oi"  clislocation  involves  miicli  more  tlian  the  mere 
luxation  of  tlie  joint,  since  in  every  case  the  injiirv  not  only  affects  the 
articiilatin<>'  surfaces,  hut  in  addition  the  liiianicnts  are  torn,  the  muscles 
are  lacerated,  the  cartilages  are  contused,  the  arteries  are  ruptured,  the 
nerves  are  stretched,  and  the  fascia  emhracinii-  the  joint  is  torn  away 
from  its  attachment.  In  compound  dislocation  the  skin  is  broken  and 
usually  destroyed,  while  the  larger  vessels  are  often  torn.  It  is  thus 
evident  that  a  dislocation  is  a  serious  injury,  and  if  it  happens  to  affect  a 
large  joint  and  is  compound  in  character,  it  involves  life  itself,  and  in 
all  cases  aff'X'ts  to  a  greater  or  less  degree  the  future  usefulness  of  the 
joint.  In  gouty,  syphilitic,  tubercular,  or  rheumatic  persons  a  dislocation 
of  a  joint  is  often  tlie  starting-point  of  a  chronic  su|)pnrativc  arthritis, 
wiiich  assumes  a  peculiar  type  according  to  the  diathesis,  and  leads 
eventually  to  resection  of  the  joint  or  even  amputation  of  the  limb. 

In  dislocation  of  the  shoulder,  occasionally,  the  branches  of  the 
axillary,  or  even  the  axillary  itself,  are  wounded,  either  bv  rujHure  of 
the  middle  and  internal  coats  or  by  rupture  of  the  three  coats  sim- 
ultaneously. If  the  former  has  occurred,  an  aneurism  slowlv  develops, 
while  if  the  latter  has  occurred,  a  rapidly-growing  traumatic  aneurism 
develops,  with  signs  of  collapse  and  gangrene  of  the  extremity.  This 
same  condition  may  obtain  in  reference  to  the  popliteal  vessels  in  dislo- 
cations of  the  knee.  The  management  of  such  ancimalous  cases  includes 
reduction  of  the  dislocation  and  an  operation  for  the  inuuediate  relief  of 
the  hicmatonia.  This  latter  operation  is  to  be  performed  according  to 
the  rules  governing  the  methods  of  treatment  discussed  under  Aneurism. 

Large  nerve-trunks  may  be  injured  as  a  result  of  a  dislocation.  The 
jiaralysis  may  be  due  to  pressure  owing  to  the  presence  of  blood  or  bone. 
This  disturbance  of  function  in  the  nerve  disappears  after  alisorption  of 
the  extravasated  blood  and  removal  of  the  bonc-ju'csstirc.  The  ])aralvsis 
may  be  due  to  laceration  of  the  nerve,  wliich  condition  is  not  likely  to 
disappear,  or  it  may  be  caused  by  injury  during  attempts  to  reduce  a 
dislocation.  A  neuritis,  or  even  traumatism  of  the  nerve-trunk,  may 
cause  a  paralysis,  and  this  condition  result  from  the  same  injury  that 
produced  the  dislocation.  In  investigating  a  dislocation  the  possibility 
of  injury  to  internal  organs  must  not  be  overlooked.  The  pelvic  organs 
in  disliicatiiin  of  the  hij),  and  the  wsojihagus  in  dislocations  of  the  clav- 
icle, are  often  tiie  seat  of  injury  which  leads  to  distui'bance  of  function 
or  destruction  of  the  organ  or  viscus. 

In  considering  the  signs  of  dislocation  it  is  not  inappro]iriate  to 
compare  tiiis  injury  with  fracture,  which  is  usually  a  less  serious  acci- 
dent. In  dislocation  the  sliaft  of  the  bone  belonging  to  the  affected  joint 
is  not  shortened,  though  the  entire  limb  may  be  shortened.  In  dislocation 
there  is  alisence  of  mobility,  and  hence  the  false  point  of  motion,  which 
is  so  characteristic  of  fracture,  is  absent  in  dislocation.  There  is  no 
tendency  for  a  dislocation  to  r"turn  after  reduction  unless  further  vio- 
lence is  exerted,  while  the  deformity  is  likely  at  once  to  reappear  in  a 
fracture  left  to  itself.  In  dislocation  there  is  often  present  a  kind  of 
crepitus  wliich  nuist  not  l>e  mistaken  for  tliat  of  fracture.  The  crepitus 
found  in  dislocations  is  of  a  peculiar  kind,  and  is  not  bonv  unless  a  frac- 
ture coexists :  it  is  due  to  blood-clots,  lymph,  ov  albumin,  and  in  .some 
cases  to  a  roughening  of  joint-surfaces. 


608  DTST.OCATIONS. 

In  tuircdvcrd  dislocation  the  result  varies  according  to  the  ]ioint  In- 
volved and  tiie  extent  of  the  injury.  Jn  the  hip  and  ankle  and  tlu;  shoul- 
der and  elbow  changes  occur  throngli  the  efforts  of  Nature,  by  means  of 
which  often  a  most  serviceable  joint  is  constructed.  The  connective  tissue 
undergoes  a  certain  amount  of  condensation,  and  mechanically  jirevcnts 
the  ho>ad  of  the  disj)lacc(l  lionc  from  fai'thcr  receding  troni  its  new  posi- 
tion. The  active  use  of  the  new  joint  causes  a  certain  amount  of  absorp- 
tion of  bone,  and  makes  the  globular  iiead  move  with  comparative  free- 
dom in  its  newly-made  socket.  The  irritation  set  up  causes  proliferation 
of  the  connective  tissue,  which  is  soon  transformed  into  fibrous  tissue, 
and  around  the  head  of  the  bone  a  comjjlete  wall  is  thus  formed,  the 
inner  side  of  which  is  lined  l)y  flat  cells  which  secrete  a  small  amount 
of  Huid,  which  in  tui'u  serves  to  lubricate  the  new  joint-socket.  Often 
some  part  of  the  synovial  membrane  is  torn  away,  and  if  nourished  con- 
tinues to  secrete  some  synovia.  The  changes  which  occur  in  the  bone 
and  its  coverings  are  of  interest  to  the  pathologist,  since  the  periosteum 
often  produces  bone  and  the  fibrous  tissue  undergoes  ossification.  The 
pressure  of  the  head  of  the  bone  on  the  periosteum,  whicli  is  not  de- 
tached from  the  bone,  causes  it  to  inflame  from  continual  irritation,  and 
thus  new  bone  is  develoj)ed  to  aid  in  the  formation  of  a  bony  cavity  for 
the  reception  of  the  displaced  head.  During  these  changes  tlie  original 
joint-socket  becomes  gradually  obliterated  by  a  process  of  absorption  and 
by  the  development  of  granulation  tissue  in  the  bottom  of  the  cavity. 
A  study  of  all  of  these  changes  in  the  new  socket,  in  the  head  of  the 
bone,  and  in  tlie  original  joint-cavity,  with  the  Ijlood-vessels  and  nerves 
imbedded  in  the  newly-formed  infiannnatory  tissue,  teaches  the  import- 
ant lesson  that  the  surgeon  must  not  overlook  the  danger  of  attempting 
by  violence  to  reduce  old  dislocations,  since  the  risk  of  tearing  vessels 
and  nerves,  and  even  of  causing  a  fatal  issue,  is  imminent. 

The  causes  of  dislocation  may  be  divided  into  predixpoxinf/  and 
e.reitinr/.  Among  the  predisposing  causes  may  be  mentioned  unusual 
freedom  of  movement  in  a  joint,  the  male  sex,  the  adult  age  of  the 
])atient,  the  arrest  of  joint-development,  and  senile  or  pathological 
absorption  of  the  head  of  the  bone  with  changes  in  the  joint-cavity. 
Among  the  exciting  causes  may  be  mentioned  mechanical  violence  and 
nmscnlar  action. 

The  signs  and  symptoms  of  dislocation  are — disturbance  of  function 
of  the  joint,  interference  with  passive  motion,  su<lden  loss  of  motion, 
absence  of  the  natural  contour  of  the  joint,  changes  in  the  relation  of 
the  muscles  about  the  joint,  alteration  in  the  shape  of  the  limb,  pain, 
tenderness,  and  ecchymosis.  Immobility  is  present,  with  no  shortening  in 
the  shaft  of  the  bone,  altliough  there  may  be  shortening  of  the  entire  limb. 

The  subsequent  effects  of  dislocation  vary  according  to  the  special 
joint  involved  and  to  the  amount  of  violence  exercised  at  the  time  of 
the  receipt  of  the  injury.  The  future  usefulness  of  the  joint  depends 
upon  the  degree  of  success  attained  in  the  reduction.  If  the  dislocation 
is  simple  and  is  quickly  reduced,  beyond  the  fact  of  a  slight  tendency  to 
a  redislocation  no  bad  effects  may  ensue.  In  certain  cases  paralysis  of 
the  limb  may  follow,  owing  to  a  concomitant  injury  of  the  nerves.  If, 
on  the  other  hand,  the  dislocation  is  compound,  amputation  or  resection 
may  be  required. 


DISLOCATIOXS.  609 

The  general  treatment  of  siin])lo  dislocations  consists  in  the  imme- 
diate reduction  and  fixation  of  tlic  joint.  Tlicrc  arc,  liowever,  certain 
causes  which  prevent  reduction,  such  as  intervention  of  soft  jiarts  ;  too 
small  tear  in  the  capsule  or  too  rapid  healing  of  the  capsule ;  absorption 
of  the  joint-cavity  ;  and,  finally,  obliteration  of  the  cavity  by  granulation 
tissue.  In  considering  the  subject  of  reduction  there  are  certain  dangers 
v.-hieh  must  not  be  overlooked,  such  as  fracture  of  the  bone,  tearing  im- 
portant vessels  like  the  subclavian,  and  even  comj)lcte  avulsion  of  tiie 
limb,  especially  when  Jarvis's  adjuster  is  employed  under  the  influence 
of  anaesthetics. 

The  question  as  to  how  long  a  dislocation  can  exist  and  yet  be  reduced 
is  one  which  interests  the  surgeon  in  connection  with  the  general  principles 
involved  in  the  treatment  of  this  injury.  There  are  rejiorted  cases  where 
the  wrist  has  been  dislocated  tor  six  years,  the  shoulder  for  two  years, 
and  the  hip  for  nearly  three  luonths,  and  yet  these  dislocations  have 
been  reduced,  but  they  are  surgical  curiosities.  As  a  rule,  after  a  fort- 
night it  is  extremely  difficult  to  reduce  a  dislocation.  In  these  days, 
however,  a  resection  can  be  made  and  a  useful  joint  obtained,  even 
though  the  dislocation  has  existed   indefinitely. 

In  case  a  fracture  coexists  with  a  dislocation,  the  reduction  of  the 
dislocation  should  precede  the  treatment  of  the  fracture,  and  in  all  cases 
in  which  shock  is  present  the  surgeon  should  avail  himself  of  this  condi- 
tion to  reduce  the  dislocation.  In  cases  where  shock  is  extreme  a  short 
delay  may  be  necessary  in  order  to  adopt  measures  to  bring  about 
reaction. 

The  treatment  of  congenital  dislocation  is  chiefly  palliative,  since  the 
absence  of  a  fully-developed  joint  makes  it  impossible  to  reduce  the 
dislocation.  Some  patients  adapt  their  movements  to  the  limited  func- 
tion of  the  joint,  while  others  lind  a  congenital  dislocation  most  dis- 
tressing. The  liability  to  fall,  or  the  loss  of  complete  function  of  a  joint, 
can  often  be  overcome  by  some  special  ai)paratus  designed  to  meet  the 
peculiar  exigencies  of  the  case.  If  the  joint  is  practically  useless  and 
tile  patient  jterfcctly  healthy,  the  question  of  forming  a  new  joint  by 
radical  opcrati\e  interference  can  be  considered. 

The  treatment  of  pathological  dislocation  involves  the  question  of 
exsection  of  the  diseased  joint  with  the  formation  of  a  false  joint.  The 
results  have  been  in  some  cases  most  satisfactory.  The  operation  must 
be  ])erformed  according  to  the  general  principles  involved  in  exsection 
of  diseased  joints. 

The  treatment  of  the  traumatic  variety  consists  in  immediately  redu- 
cing the  dislocation.  The  object  can  be  accomplished  by  manipulation  or 
by  extension  and  counter-extension.  The  manipulative  method  is  the 
simplest,  and  is  generally  successful  if  attempted  during  the  relaxation 
of  the  muscles  consequent  upon  shock  or  ana\sthesia.  If  reaction  from 
shock  has  taken  place  and  the  .nusclcs  are  in  a  condition  of  spasmmiic 
contraction,  an  aiuesthetic  is  indicated,  since  the  nuisclcs  become  at  once 
relaxed  and  the  reduction  is  accomplished  without  any  difficulty. 

In  employing  manipulation  the  surgeon  endeavors  to  reduce  the  dis- 
location l)v  relaxing  those  muscles  which  by  their  contraction  prevent 
the  return  vt'  the  head  of  the  l)one  into  the  socket,  and  also  liy  certain 
movements  to  make  the  head  of  the  dislocated  bone  travel  back  by  the 

Vol.  I.— 39 


filO 


DISLOCATIONS. 


.same  route  by  which  it  made  its  cscaj)e  from  tlio  joint.     If  niaiiipiilatioii 
fails  to  restore  the  joint  to  its  normal  eondition,  tiic  use  of  extension 
and  counter-extension  is  indicated. 
In  eni) 


n  enipiovniij;  c.vlcnuioii  and  cotintcr-c.vtcnmon  tlie  surgeon  endeavors 


Fi(i.  129. 


Jarvis's  adjuster  applied  for  reduction  of  a  dislocation  of  the  hip. 

to  overcome  by  force  the  contraction  of  tlie  muscles  which  act  as  the 
chief  barriers  to  the  reduction  of  the  dislocation.  The  object  is  to  over- 
come all  sources  of  resistance  of  whatever  kind  liy  the  application  of  a 

Fig.  130. 


Reduction  of  a  dislocation  on  the  dorsum  ilii  by  the  Spanish  windlass  (Gilbert). 

force  sufficient  to  aecomjilish  tlie  end.  Many  serious  accidents  have  hap- 
pened in  trying  to  reduce  old  dislocations  by  a  too  violent  exercise  of 
force.     Limbs  have  been  entirely  torn   from   the  body,  large   arteries 


TREATMENT  OF  DISLOCATIONS. 


611 


Fig.  131. 


have  been  raptured,  important  veins  have  been  torn,  main  nerve-trunks 
have  been  irreparably  lacerated,  bone.s  have  been  fractured,  muscles  and 
fascia  have  been  torn  from  tiieir  insertions,  and  g-angrene  of  the  limb 
has  been  produced.  All  these  accidents  have  occurred,  and  in  some  cases 
with  fatal  results.  Since  the  introduction  of  anaesthetics  these  fatalities 
have  been  numerically  lessened,  but  it  must  not  be  forgotten  that  the 
influence  of  the  anaesthetic  is  in  itself  a  source  of  very  great  danger. 
Jarvis's  adjuster  (Fig.  129)  is  one  of  the  means  which  are  emjiloveil 
to  reduce  old  dislocations.  The  instrument  is  so  constructed  that  ex- 
tension is  made  by  a  ratchet,  and  counter-extension  by  a  perineal  band 
attached  to  a  long  shaft  fixed  to  the  limb.  The  8j)anish  windlass 
(Fig.  130),  as  suggested  by  Gilbert,  and  the  Bloxam  "  dislocaticm 
tourniquet"  (Fig.  l-'il)  are  also  employed.  Hippocrates  designed  an 
instrument  for  the  ])urpose  of  reducing  old  dislocations.  There  are 
other  instruments  with  certain  mechanical  \ari- 
ations,  all  of  which  have  one  common  object  in 
view.  It  seems  unnecessary  to  give  any  special 
description  of  the  different  varieties  of  apparatus 
proposed  for  this  purpose,  since  their  employ- 
ment has  been  jiractically  abandducd  on  account 
of  the  intn)duction  of  manijuilation  under  an- 
£esthesia,  and,  in  the  event  of  failure  to  reduce 
the  dislocation  by  this  method,  it  is  preferable  to 
cut  down  directly  ujjon  the  joint  and  divide  all 
structures  offering  any  obstruction  to  the  reduc- 
tion, scraping  out  the  joint-cavity  if  necessary, 
and  returning  the  head  of  the  bone  into  its 
proper  place.  This  operation,  with  every  anti- 
septic precaution,  is  immeasurably  safer  than  the 
use  of  any  of  the  powerful  instruments,  \\ith 
the  exception  ]X'rhaps  of  the  comjjound  ]>ulleys 
(Fig.  132),  which  can  be  used  with  a  certain 
amount  of  ssifety  in  careful  hands.  Malgaigne  has  laid  down  the  rule 
that    no    force    beyond    440    pounds  should  ever    be  employed,  and  a 

Fig.  132. 


Bloxam's  dislocation  tournl- 
yuet. 


CVimpmmrl  pulleys,  and  rini.'  to  which  one  end  of  llic  i.uUcy-rope  is  fiistened. 

dynami)meter  should  be  attached  to  the  pulleys  in  order  to  ascertain  tli 
precise  amount  of  force  exercised. 


()12  DISLOCATIONS. 

In  some  cases  spc('i;illy-coiistrtict«l  fon'cps,  or  the  Indian  puzzle  (see 
page  626),  or  the  ck)ve-hitch  (Fig.  133)  with  a  wet  towel,  may  he  employed 

Fig.  133. 


I'     ' 

Clove-hitch  (Ei-ii  lison). 


M'ith  comparative  safety  under  the  influence  of  an  anipsthetie.  Subcu- 
taneous division  of  tendons  often  aids  the  surgeon  in  the  accomplish- 
ment of  his  object,  aiid  this  simple  operation  caunot  be  too  highly 
recommended. 

Too  prolonged  extension  should  never  be  employed,  since  serious 
damage  can  arise  from  this  cause.  No  surgeon  should  continue  perma- 
nent extension  over  twenty  consecutive  minutes.  All  adhesions  should 
be  broken  up  as  far  as  possible  before  aj)plying  the  extending  and 
counter-extending  force,  as  this  is  often  of  signal  benefit  in  antici|)ation 
of,  and  in  conjunction  with,  the  employment  of  forced  extension. 

After  a  dislocation  has  been  successfully  reduced  the  joint  should  be 
immi)val)ly  fixed  for  at  least  a  week,  after  which  time  the  dressings 
should  be  rem<jved,  and  a  slight  amount  of  passive  motion  employed  to 
prevent  adhesions  and  to  overcome  any  contraction  of  the  muscles  and 
ligaments.  Active  motion  should  not  be  permitted  for  at  least  a  fort- 
night, and  in  some  joints  not  for  a  month,  since  this  might  provoke 
inflammatory  reaction,  tear  anew  the  capsule,  and  cause  a  recurrence  of 
the  dislocation.  In  case  any  stiffness  or  rigidity  of  the  joint  remains, 
galvanism,  massage,  shampooing,  and  inunctions  of  oil  often  assist  in 
restoring  the  usefulness  of  the  joint. 

The  general  treatment  of  compound  dislocations  is  largely  influenced 
by  the  particular  joint  involved  and  the  extent  of  the  joint-injury. 
Besides  the  displacement,  the  soft  tissues  about  the  joint  are  lacerated,  the 
ligaments  are  torn,  the  "  synovial "  capsule  is  opened,  and  the  tendons, 
mu.sclcs,  and  vessels  are  ruptured.  In  some  cases  a  fracture  coexists, 
and  this  extensive  damage  gives  rise  to  inflammation,  suppurative 
arthritis,  abscess,  cellulitis,  and  even  gangrene.  The  condition  which 
confronts  the  surgeon  is  serious,  not  only  for  the  future  usefulness  of 
the  joint,  but  for  the  life  of  the  patient.  There  are  three  plans  of 
treatment  which  must  be  considered — conservative  surgery,  primary 
resection  of  the  joint,  and  amputation.  The  general  rules  governing  the 
.surgeon  in  this  dilemma  have  already  been  mentioned,  and  consist  of 
consideration  of  the  special  joint  involved,  the  age,  constitution,  and 
hygenic  surroundings  of  the  patient. 

Conservative  treatment  involves  the  question  of  the  preservation  of  the 


TREATMENT  OF  DISLOCATIONS.  613 

joint,  without  at  the  «inie  time  exposing'  the  patient's  life  to  too  great  a 
rislv.  In  all  the  joints,  except  tiie  knee,  it'  the  skin  is  not  seriously 
damaged  and  the  vessels  are  uninjured,  conservatism  can  be  practised. 
In  the  case  of  the  knee  this  plan  can  he  adopted  only  if  the  vessels  are 
uninjured,  the  ])atient  is  young  and  healthy,  and  the  wound  in  the  soft 
parts  small.  To  meet  with  success  in  tiie  conservative  jtlan  the  soft 
j)arts  ahout  tiie  joint  should  he  rendered  immediately  aseptic,  the  wound 
if  small  should  he  sufficiently  enlarged  to  enable  the  surgeon  to  explore 
thoroughly  the  joint,  which  should  be  irrigated  with  a  warm  bichloride 
solution  of  1  :  10,(300,  and  then  a  large-sized  rubber  drainage-tube  intro- 
duced into  and  through  the  joint,  so  that  one  end  at  least  is  in  the 
dependent  jjortion  of  the  joint.  The  enlarged  wound  can  be  sutured  so 
as  to  close  it  sutiicicntly  to  allow  the  tube  to  ])roject  flush  with  the  sur- 
face of  the  skin.  The  parts  are  now  thoroughly  again  irrigated,  and 
antiseptic  dressings  applied,  over  which  absorbent  cotton  shoidd  be  placed 
so  as  to  include  the  entire  limb,  and  a  ]>laster-of- Paris  bandage  supported 
with  a  few  strips  of  tin  or  zinc  to  strengthen  it.  In  three  to  five  days 
a  fenestruni  should  be  cut,  the  joint  again  irrigated  through  the  tube, 
which,  if  the  temperature,  pidse,  and  respiration  are  normal,  can  either 
be  entirely  removed  or  at  least  shortened,  and  finally  removed  at  a  sub- 
sequent dressing  in  forty-eight  hours.  This  ilrcssing  should  be  conducted 
witli  the  same  antiseptic  precautions  and  under  continuous  irrigation,  pre- 
<-isely  in  the  same  manner  as  the  initial  dressing.  The  plaster  sliould 
remain  on  for  at  least  four  weeks,  and  then  gentle  passive  motion  should 
be  employed,  and  at  the  expiration  of  two  additional  weeks  a  limited 
amount  of  active  motion  should  be  permitted.  If  this  plan  has  failed, 
suppurative  arthritis  ensues,  and  a  secondary  resection  or  amputation 
must  be  performed. 

Primary  exci.sioii  of  the  joint  is  the  second  plan  of  treatment  when  it 
is  not  considered  best  to  attempt  conservative  measures.  In  this  case 
the  joint  is  widely  opened,  the  loose  pieces  of  comminuted  bone  are 
removed,  the  torn  fascia  is  cut  away,  and  the  wound  is  rendered  aseptic. 
In  the  shoulder-,  elbow-,  wrist-,  and  ankle-joints  a  movable  joint  should 
be  secured,  while  in  the  knee  an  osseous  ankylosis  is  probable.  Primaiy 
excisions  are  very  unfavorable  as  compared  with  secondary  resections, 
and  a  ease  of  primary  excision  under  these  conditions  gives  rise  to  great 
anxiety. 

Pr'unari/  (iiiijiiitdtion  is  indicated  where  it  is  not  best  to  attempt  either 
a  conservative  j)lan  or  a  primary  excision,  and  therefore  embraces  a  class 
of  cases  found  in  elderly  persons  in  whom  the  joint  is  seriously  damaged 
and  the  main  vessels  are  torn. 

Dislocation  of  the  ribs  is  seldom  observed,  since  they  have  very 
limited  motion  and  great  elasticity,  and  are  held  together  by  strong  lig- 
anicrits.  Tiie  ribs  iii'ay  be  separated  from  the  bodies  of  the  vertebne  in 
fracture  of  the  spine,  in  which  case  the  head  of  the  rib  is  found  lying 
upon  the  front  of  the  .spine.  The  ribs  may  also  be  dislocated  in  con.se- 
quence  of  severe  fills,  or  even  blows  upon  the  back,  with  or  without 
fracture  of  the  spine. 

The  sig-ns  and  symptoms  of  this  dislocation  are  obscure,  and  are 
generally  arrived  at  liy  exclusion.  There  is  a  depression,  with  no  crep- 
itus, but  with  a  peculiar  grating  sound,  caused  by  the  head  of  the  rib 


()U  DISLOCATIONS. 

ridiiifi'  on  the  front  of  the  spine  wlieii  tlie  rilj  is  pusiied  from  the  front  ; 
the  pain  is  sometimes  very  severe. 

The  treatment  is  substantially  the  same  as  it  wouiti  he  in  fracture 
of  the  l)oue. 

Dislocation  of  the  c'ai;tila(;k.s  from  tiie  sternum  oeeurs  especially 
in  young  people.  The  first  rib,  having  no  synovial  capsule  and  true 
joint,  is  so  protected  that  it  is  not  liable  to  dislocation.  The  second  to 
tile  seventh  ribs  may  become!  dislocated  at  their  junction  with  the  sternum. 
The  accident  may  be  complicated  witli  fracture  of  the  stei-num. 

CosTO-STERNAL  Di.si/)CATiON  may  occur  as  a  residt  of  a  blow,  or  in 
consequence  of  a  sudden  violent  com})ression  of  the  chest,  or  even  by 
muscular  action. 

The  sig-ns  and  symptoms  are  the  presence  of  a  subcutaneous  tumor 
u[)on  the  front  of  the  sternum,  produced  by  the  dislocated  cartilage,  and 
severe  pain  over  the  site  of  tlie  injury. 

The  treatment  isists   in   reducing  tlie  <lislocation   l)y  making  tlie 

patient  assume  the  position  of  opisthotonos  and  pushing  the  projecting 
end  into  its  proper  place.  If  the  patient  is  unable  voluntarily  to  assume 
tliis  ]iosition,  a  sand-bag  can  be  placed  between  the  scajiulse  and  the 
shoulders  pushed  back,  when  the  dislocated  end  will  usually  resume  its 
U(U-mal  position.  A  tirm,  hard  compress  should  be  jdaced  over  the  dis- 
located cartilage  and  hehl  in  situ  Ijy  broad  strips  of  adhesive  plaster, 
which  should  encircle  the  thorax. 

DlSLOL'ATION    OF    THE    SIXTH  TO  TIIE    TENTH  "CARTILAGES  from  One 

another  occurs  as  a  result  of  a  fall  upon  the  back  or  in  consequence  of 
a  violent  contraction  of  the  pectoral  or  abdominal  muscles.  The  upper 
margin  of  the  lower  cartilage  slips  beneath  the  upjier  cartilage. 

The  signs  and  symptoms  are  severe  pain  and  prominence  of  the 
cartilage. 

The  treatment  consists  in  instructing  the  patient  to  take  a  deep,  full 
inspiration,  and  tlien  attempting  to  disengage  the  dislocated  cartilage. 
The  same  kind  of  a  bandage  which  is  employed  in  fracture  of  the  rib 
sliould  be  applied  witli  a  eomjiress  over  the  site  of  the  lesion.  This  will 
help  to  hold  the  dislocated  end  in  place  and  serve  also  to  restrain  the 
movements  of  the  thoracic  parietes. 

Dislocation  of  the  sternum  occurs  at  the  junction  of  the  manu- 
brium with  the  gladiolus,  where  an  arthrodial  joint  exists.  The  injury 
is  caused  in  the  same  manner  as  a  fracture,  presents  many  of  the  same 
signs  and  sym]>tonis,  and  requires  the  same  treatment. 

Dislocations  of  the  clavicle  occur  either  at  the  sternal  or 
acromial  end.  These  dislocations  are  extremely  rare,  on  account  of  the 
strength  of  the  short  ligaments,  and  in  this  resjiect  differ  from  frac- 
tures of  the  clavicle,  which  are  exceedingly  common.  Dislocation  of 
the  clavicle  at  the  sternal  end  may  be  forward,  backward,  or  upward. 

The  forward  dislocation  is  caused  by  some  violence  ajqilied  to  the 
acromial  end  of  the  clavicle,  by  a  fiill  upon  the  front  of  the  sliouldcr,  or 
in  liending  the  shoulder  suddeiilv  backward  in  certain  gymnastic  move- 
ments. The  writer  has  seen  a  dislocation  of  the  clavicle  occur  in  playing 
lawn  tennis.  The  dislocated  end  of  the  clavicle  lies  upon  the  front  of 
the  sternum  just  beneath  the  articular  facet,  and  upon  the  sternal  origin 
of  the  steruo-cleido-mastoid  muscle  (Fig.  134). 


SPECIAL  DISLOCATIONS. 


615 


Fig.  134. 


Dislocation  of  the  sternal  end  of  the 
clavicle  forward. 


The  signs  and  symptoms  con.sist  of  a  subcutaneous  tumor,  produc- 
ing a  prominence  upon  the  front  of  the  manubrium  ;  the  aljrujtt  ending 
of  the  chivicle ;  the  shortening  between  the  slioulder  and  the  mesial  line 
of  the  sternum  as  compared  ■with  the  opposite  side  ;  the  inclination  of  the 
head  to  the  affected  side,  owing  to  the  fact  that  the  sterno-cleido-mastoid 
muscle  is  made  tense  by  the  protrusion 
of  the  clavicle  against  it ;  and  severe  pain, 
increased  bv  any  movement. 

The  treatment  consists  in  dniwing 
back  simultaneously  both  shoulders  by 
placing  the  knee  in  the  interscapular 
space,  and  then  having  the  end  pushed 
into  its  proper  place.  A  firm  compress 
should  be  immediately  applied  over  the 
site  of  the  dislocation  and  held  in  tiifil  by 
adhesive  plaster  and  bandages.  If  the 
dishicated  cud  lias  a  tendency  to  slip  out, 
and  thus  to  cause  the  deformity  to  reap- 
pear, and  if  all  the  circumstances  are  favorable,  the  tlislocated  end  can  be 
fastened  by  a  metallic  suture. 

Dislocation  of  the  clariele  backward  occurs  in  consequence  of  a  kick 
from  a  horse  or  a  fill  npt)n  the  shoulder.  The  dislocation  may  be  a 
pathological  one,  secondary  to  lateral  curvature  of  the  spine.  The  dis- 
located end  may  be  thi-ust  backward  and  slightly  upward,  just  above  its 
natural  jjosition,  or  it  may  be  pushed  downward  just  behind  the  sternum, 
beneath  the  articulating  facet,  near  the  origins  of  the  sterno-hyoid  and 
sterno-mastoid  muscles. 

The  signs  and  symptoms  consist  of  pain,  k)ss  of  function  of  the 
affected  arm,  turning  of  the  head  toward  tiie  dislocated  side,  approxima- 
tion of  the  shoulder  to  the  mesial  line  of  the  sternum,  a  fossa  at  the 
articular  facet,  dyspnoea  from  pressure  on  the  trachea,  or  dysphagia 
from  compression  of  the  oesophagus,  or  disturbance  in  both  res]iiration 
and  deglutition  if  the  dislocated  end  is  driven  down  liehind  the  sternum. 
If  the  end  of  the  bone  descends  low  enough,  it  may  by  pressure  on  the 
subclavian  arterj'  cause  diminution  or  cessation  of  the  radial  pulse,  or 
by  pressure  upon  the  brachio-cephalic  vein 
prevent  the  return  current  in  the  vessel 
and  cause  passive  hyperemia. 

Treatment. — The  dislocation  can  usu- 
ally be  reduced  by  the  means  already  de- 
scril)ed,  but  in  case  the  bone  cannot  be 
returned  to  its  proper  position,  and  diffi- 
culty of  respiration  and  deglutition  is 
present,  the  end  of  the  bone  should  be 
sawed  off  to  relieve  the  pres.^^ure.  Thi.s 
procedure,  however,  is  seldom  nece.s- 
.sirv. 

Dis/ocution  of  the  clavicle  upirard 
occurs  as  a  result  of  indirect  violence,  and  is  exceedingly  rare. 

The  signs  and  symptoms  are  tumor,  formed  by  the  projecting  end 
just  beneath  the  in.sertion  of  the  sterno-cleido-mastoid  muscle  (Fig.  135); 


Fig.  135. 


Dislocation  of  the  sternal  end  of  the 
clavicle  upward. 


(5  Hi  DISLOCATIONS. 

slidi'tciiino;  from  tho  tip  of  (lie  sliouldcr  to  tlic  mesial  lino  of  the  ster- 
num ;  tx'casional  (lys|ni(>'a  from  iircssurc-t'lft'cts;  and  sonu'tiines  (lyspiiaii'ia. 

Tile  treatment  is  suhstantialiy  tlie  same  as  lias  already  l)een  described 
in  conneetion  with  otiier  dislocations  of  this  bone.  In  addition,  an  axil- 
lary pad  can  be  employed  as  a  fidcrnm,  so  as  to  use  the  arm  as  a  lever, 
and  tlins  the  clavicle  can  be  drawn  away  from  tlie  mesial  line,  and  its  dis- 
located end  I)V  manijiuiation  be  pushed  into  the  articiilatini;-  socket,  where 
it  can  be  retained  by  compresses  and  a  Velpcau  dressinjj,  with  the  elbow 
brought  well  forward.  It  is  often  very  <litHcult  to  keep  the  dislocated 
end  in  place,  and  if  the  arm  is  rendered  useless  by  the  permanently 
tmrediiced  dislocation,  it  can  be  wired  to  the  sternum  by  an  antiseptics 
operation. 

DiNlordtumK  of  tlif  acroinidl  end  of  llir  cJaride  are  not  so  fi'c(|Ucnt  as 
at  the  sternal  end,  on  account  of  the  stronir  conoid  and  trapezoid  iiga- 
ments  which  bind  this  part  of  the  clavicle  down  to  the  scapula.  The 
accident  usually  occurs  as  a  result  of  a  severe  blow  upon  the  back  part 
of  the  shoulder  or  of  a  fall  from  a  height  upon  the  outer  part  of  the 
shoulder.  The  bone  may  be  dislocated  upward  or  downward.  In  the 
upward  variety  the  end  of  the  l^one  is  found  upon  the  superior  surface 
of  the  acromion  process  of  tiie  scapula. 

Besides  the  presence  of  the  tumor,  the  signs  and  symptoms  are 
severe  pain,  inability  to  use  the  arm,  depression  of  the  affected  shoulder, 
approximation  of  the  shoulder  to  the  mesial  line  of  the  sternum,  length- 
ening of  the  arm,  which  hangs  close  to  the  side  of  the  thorax,  and  con- 
traction of  the  clavicular  portion  of  the  trapezius  muscle. 

The  treatment  consists  in  reducing  the  dislocated  end  by  pushing  it 
down  into  its  socket  after  drawing  the  shoulder  well  backward.  The 
axillary  pad  may  be  necessary,  in  which  case  it  acts  as  a  fulcrum  and  the 
humerus  as  a  lever.  Sometimes  the  arm  can  be  raised  to  a  right  angle 
with  the  trunk,  and  in  this  position  the  dislocation  will  slip  into  place. 
The  trapezius  muscle  has  a  tendency  to  elevate  the  dislocated  end,  and 
if  it  can  be  isolated  and  divided  by  a  tenotome,  the  displaced  end  will 
be  held  in  place  until  the  tendon  has  united.  When  the  bone  has  been 
reduced  great  difficulty  is  found  in  holding  it  in  place.  Compresses  have 
been  used  over  the  end,  and  these  bound  down  firmly  by  long  strips  of 
ruijber  or  adhesive  plaster.  The  skin  soon  becomes  excoriated  by  the 
plaster,  and  the  patient  is  unable  to  tolerate  the  dressing.  In  these  cases 
the  metallic  suture  under  proper  antiseptic  precautions  is  indicated,  and 
the  bone  can  thus  be  permanently  fixed  in  its  proper  position. 

D'wlocation  of  the  ncroiaicd  end  downward  is  an  exceedingly  rare 
accident.  The  injury  is  the  result  of  a  blow  from  above  directly  upon 
the  clavicle,  or  a  fall  in  -which  the  body  is  thrown  forward  and  the  force 
of  the  fall  impinges  upon  the  ujiper  surface  of  the  clavicle.  In  this  dis- 
location the  acromio-clavicular  ligaments  are  ruptured,  and  the  end  of 
the  bone  rests  upon  the  capsule  of  the  shoulder-joint,  or  it  ma}'  descend 
and  be  found  beneath  the  coracoid  process  of  the  scapula. 

The  signs  and  symptoms  are  projection  inward  of  the  superior  angle 
of  the  scapula  and  protrusion  outwai'd  of  the  inferior  angle  of  the  same 
bone,  great  pain  and  tenderness,  marked  depression  over  the  inner  side 
of  the  acromion,  inability  to  move  the  arm,  and  projection  of  the  coro- 
noid  process. 


SPECIAL  DISLOCATIOXS.  617 

The  treatment  consists  in  rc'tliifinu-  tlie  dislocation  by  dra^^^ng  the 
shoulders  outward  and  backward  and  jnishing  the  interior  angle  of  the 
scapula  in\yard.  The  scapula  should  be  held  in  slfii  by  compresses  in  a 
manner  similar  to  that  described  in  treating  fractures  of  this  bone. 

Dixhieatlon  of  the  clavicle  simultaneouali/  uf  the  acromion  and  sternal 
eiiiln  has  ix'en  reported  by  a  few  surgeons.  The  accident  occurred  in 
falls  upon  the  back  of  the  shoulder. 

The  signs  and  symptoms  are  those  indicated  in  the  respective  dis- 
locations, and  the  treatment  consists  in  reduction  by  the  plan  already 
described. 

DiSLOCATiox  OF  THE  SCAPULA  occurs  as  a  result  of  the  bone  slipping 
from  under  the  tendon  of  the  latissimus  dorsi  muscle,  which  traverses 
and  covers  the  inferior  anffle  of  the  scajnda.  This  bone  may  also  become 
dislocated  as  a  result  of  paralysis  of  the  serratus  magnus  muscle  or  the 
long  thoracic  nerve. 

The  signs  and  sjrmptoms  arc  a  wing-like  projection  of  the  dorsal 
border  of  the  inferior  angle  of  the  scapula,  and  loss  of  motion  in  certain 
movements  of  the  arm  anil  shoulder. 

The  treatment  consists  in  replacing  the  bone  under  the  latissimus 
dorsi  tendon  and  holding  it  in  its  proper  position  by  compresses,  wliioli 
in  turn  are  held  in  place  by  some  apparatus  similar  to  that  employed  in 
fracture  of  the  rib.  If  the  displacement  is  due  to  paralysis  of  the  mus- 
cle, hypodermic  injections  of  strychnia  into  its  substance,  combined  with 
the  use  of  electricity,  iron,  and  massage,  will  often  relieve  the  troul)lc. 

Disi.ocATiOX  OF  THE  SHOFLiiER-.loiNT  occurs  more  frequently  than 
dislocation  of  any  other  joint  in  the  Ixidy,  forming  a  little  over  50  per 
cent,  of  all  dislocations.  This  fact  is  due  to  certain  anatomical  features 
of  the  joint,  such  as  great  freedom  of  motion,  shallowness  of  glenoid 
cavity,  laxity  of  capsular  ligament,  absence  of  muscles  adapted  to  give 
support  and  strength,  and,  finally,  to  the  immense  leverage  oMing  to 
the  length  of  the  upjier  extremity. 

The  shoulder  may  be  dislocated  by  indirect  violence,  as  a  foil  upon 
the  elbow  or  hand,  or  by  direct  violence,  as  a  severe  blow  upon  the  ante- 
rior or  posterior  part  of  the  shoulder  while  the  arm  is  separated  from 
the  body,  or,  finally,  by  muscvlar  action. 

The  varieties  of  dislocation  of  the  shoulder  are  subcoracoid,  sub- 
glenoid, subspinous,  and  subclavicular. 

The  Hnhcoracnid  varieti/  is  the  most  frequent.  The  head  of  the 
bone  lies  under  the  coracoid  process  of  the  scapula  (Fig.  136),  and 
escapes  from  the  joint  through  a  tear  in  the  inner  and  lower  part 
of  the  capsule,  where  the  opening  of  the  biceps  bursa  begins.  The 
anatomical  neck  lies  upon  the  anterior  lip  of  the  glenoid  cavity,  and 
tile  posterior  part  of  the  capsule  is  stretched  tightly  across  the  glenoid 
f  >ssa.  The  tendon  of  the  biceps  is  usually  pulled  out  of  its  groove,  and 
the  muscles  attached  to  the  tuberosity  are  torn  from  their  insertion  into 
the  bone.  In  this  variety  the  axillary  vessels  are  usually  not  pressed 
upon  by  the  head  of  the  bone. 

The  snhf/lenoid  varieti/  appears  next  in  point  of  frequency,  and  the 
head  of  the  bone  escapes  either  below  the  insertion  of  the  subscajnilaris 
nuiscle  (Fig.  137)  or  forces  its  way  through  the  substance  of  the  nuiscle 
itself.     The  capsule  is  torn  below,  and  the   head  of  the  bone  causes 


618 


DISLOCATIONS. 


compression  of  the  axillary  vessels  an<l  nerves,  which  results  in  oedema, 
cyanosis,  and  great  pain. 

The  mljclaricular  i-drirli/  is  rare.     Tlie  licail  cif  (iic  hdiie  is  carried 
to  the  inner  side  of  the  coracoid  process  heneatii  and  across  the  pectoral 


Fig.  136. 


Fid.  137. 


Subcoracoid  dislocation  of  the  shoulder. 


Subglenoid  dislocation  of  the  humerus. 


muscle,  and  is  prominent  under  the  skin.  In  this  variety  the  external 
rotators  attached  to  the  greater  tuberosity  are  completely  torn  from 
their  insertion,  or  else  the  Ijony  process  is  fractured.  This  dislocation 
is  tlie  result  of  great  violence  (Fig.  138). 


Fig.  138. 


Fig.  139. 


Dislocation  of  the  shoulder  downward 
under  the  clavicle. 


Subspinous  dislocation  of  the  shoulder, 
unreduced ;  new  socket  formed. 


The  subspinoiis  variety  is  found  where  the  posterior  and  lower  part 
of  the  capsule  has  been  torn  (Fig.  139),  and  the  head  of  the  bone  is 
forced  to  rest  upon  the  dorsal  surface  of  the  scajjula  below  the  spine 
and  beneath  the  infraspinatus   muscle.     In    this  variety  the  subscap- 


SPECIAL  DISLOCATIONS. 


619 


Tilaris  nmscle  is  strctclied  iun'oss  tlie  glenoid  cavity  in  the  same  manner 
as  the  external  rotators  are  in  the  forward  varieties  of  disloeation. 

In  addition  to  these  four  varieties,  occasionally  there  are  slight 
departures  from  the  ordinary  types — for  example,  subacromial  or 
supra-coracoid — but  a  careful  examination  of  tiie  injured  joint  will 
demonstrate  the  fact  that  these  variations  arc  ditlerent  in  degree  and  not 
in  kind. 

The  signs  and  symptoms  of  dislocation  of  the  shoulder  are  very 
similar,  irrespecti\e  of  the  special  variety.  They  ai'e — flattening  of  the 
shoulder ;  prominence  of  the  acromion  ;  depression  beneath  the  acro- 
mion ;  absence  of  the  head  of  the  bone  from  the  glenoid  cavity  ;  pre- 
ternatural immobility ;  pain  in  the  joint  and  along  the  cords  of  the 
bracliial  plexus ;  rigidity  of  the  surrounding  nnisclcs  ;  inclination  of 
the  patient's  head  toward  the  atiected  joint  ;  flexion  of  tiic  ell)ow  to 
relax  the  biceps ;  obliteration  of  the  infra-clavicular  fossa ;  prominence 
of  the  head  of  the  bone  under  the  skin  in  certain  varieties  ;  axis  of  limb 
abducted  ;  «dema  from  mechanical  pressure ;  the  affected  foreai'm  is 
supported  by  the  ojtposite  hand  ;  the  anterior  axillary  fold  is  less  prom- 
inent ;  and  the  head  of  the  bone  is  felt  in  the  axilla  or  bcneatli  the  skin 
below  the  acromion  or  the  clavicle. 

In  addition  to  these  signs,  Hamilton  has  demonstrated  that  a  ruler 
placed  upon  the  acromion  will  touch  the  external  condyle  of  the  humerus 
in  a  dislocated  joint ;  Callaway  has  shown  that  the  vertical  mcasin-ement 
over  the  acromion  and  around  the  axilla  is  some  two  inches  greater  upon 
the  afl'eeted  side ;  and  Dugas  has  proved  that  in  disloeation  of  the 
shoulder  the  hand  cannot  touch  the  ojjposite  shoulder  if  the  elbow  of 
the  affected  side  is  brought  in  contact  with  the  thorax. 

The  signs  of  dislocation  of  the  shoulder  must  be  distinguished  from 
those  of  fractures  of  the  upper  end  of  the  humerus  and  of  the  neck  of 
the  scapula,  and  from  those  of  paralysis  of  the  deltoid  muscle. 


Fig.  140. 


Sir  .\stley  Cooper's  metlioil  of  applying  extension  with  the  heel  in  the  axilla. 


PiinJjixix  of  flir  (Ic/toid  is  diagnosticated  by  the  presence  of  unusual 
mobility  in  the  joint,  by  tlie  relaxation  of  the  muscles,  bv  inability  to  rai.se 
the  arm  at  right  angles  to  tlie  trunk,  l)y  the  negative  results  of  Dugas's  and 


620 


DISLOCATIONS. 


Callaway's  tests,  and,  finally,  by  the  presence  of  the  head  of  the  humerus 
in  the  ujlenoid  cavity.  This  condition  can  also  be  ascril)cd  to  some 
traumatisin  affecting  the  deltoid  nniscle. 

The  FKACTURE8  OF    THK    ri'I'KI!    EXI)    OF  THE    HUMERUS,  including 

those  of  tl)e  anatomical  and  surgical  neck  and  the  tuberosity,  are  distin- 
guished l)y  tiie  signs  already  gi\-cn  under  Fractures.  The  fracture  of 
tile  neck  of  tiie  scapula,  besides  the  ordinary  signs  of  fracture,  has  one 
])eculiarity — viz.  the  defcjrraity  can  be  at  once  removed  by  simjjly  lifting 
the  entire  arm  u[)\vard,  when  the  normal  relations  of  the  joint  are  imme- 
diately restored,  hut  only  so  long  as  the  arm  is  supported  l)v  the  surgeon, 
since  withdrawal  of  the  support  is  f()llowed  by  a  return  of  the  defonnitv. 
Tiie  treatment  of  dislocation  of  the  humerus  may  be  accomjilisiied 
by  Kocher's  method,  by  flexion  of  the  forearm  upon  the  arm  to  a  right 
angle  and  then  bringing  it  close  to  the  side.  The  surgeon  then  grasps 
the  forearm  thus  flexed  and  turns  it  away  from  the  body  as  far  as  pos- 
sible, to  cause  external  rotation  of  the  arm.     During  this  movement  the 

head  of  the  btjue  rolls  outward  in  front 
Fig.  141.  of  ;nid  below  the  acromion,  the  elbow 

is  tiien  carried  well  forward  and  up- 
ward, and  then  the  arm  is  rotated  in- 
ward and  the  elbow  lowered.  Manipu- 
lation by  an  assistant  with  his  hand  in 
the  axilla  is  often  of  great  service. 

Sir  Astley  Cooper's  method  consists 
in  the  surgeon  making  extension  with 
his  foot  in  the  axilla  while  the  patient 
lies  upon  the  edge  of  a  table  or  upon 
the  floor  (Fig.  140). 

The  same  method  can  be  employed 
by  the  surgeon  standing  behind  and 
])lacing  his  knee  in  the  axilla  of  the 
])atient,  who  is  seated  upon  a  low  stool. 
The  surgeon  now  presses  down  upon 
the  acromion  process  (Fig.  141)  with 
one  hand  and  makes  traction  downward 
upon  the  arm  with  the  other  hand, 
while  at  the  same  time  he  raises  his 
heel  so  as  to  push  the  head  of  the  bone 
outward.  This  method ,  combines  extension,  leverage,  and  abduction 
with  manipulation. 

Skey  used  an  iron  knob  (Fig.  142)  in  place  of  the  heel  in  the  axilla, 
in  conjunction  with  the  use  of  compound  pulleys  (Fig.  143). 

Fig.  142. 


Sir   Astley   Cooper's  mode  of  operating 
with  the  knee  in  the  axilla. 


Iron  knob  employed  hy  Skey,  instead  of  the  heel. 

Wood  reduced  these  dislocations  by  having  an  assistant  stand  upon  a 
firm  table  and  make  counter-extension  with  a  towel  passed  under  the 


SrECIA L  DISLOCA TIONS. 


G21 


axilla  of  the  patient,  who  stands  by  the  side  of  the  tahle  wiiile  the  sur- 
geon makes  extension  from  tiie  arm  below. 

H.  H.  Smith  employed  the  following  method  :  "  Elevate  the  elliow 
and  arm  as  high  as  possible  and  Hex  the  forearm  at  right  angles  with  the 
arm,  thus  relaxing  the  supraspinatus  muscle.     Then,  using  the  forearm 


Fig.  143. 


Skcy's  mc'tliocj  of  makinj;  extension  sine!  counter-extension  witli  pulley. 


as  a  lever,  rotate  the  head  of  the  humerus  upwai'd  and  forward,  so  as  to 
relax  the  infraspinatus  muscle,  carrying  the  rotation  as  far  as  possible 
or  until  resisted  by  the  action  of  the  subscapnlaris  muscle,  keeping  the 
forearm  for  a  few  .seconds  in  its  ])osition  with  the  palm  of  the  hand 
looking  upward  ;  then  bring  the  elbow  promjitly  but  steadily  down  to 
the  side,  cai'rying  the  elbow  toward  the  body  and  keeping  the  forearm 
so  that  the  palm  of  the  hand  yet  looks  to  the  sui-geon.  Then  quickly 
but  gently  rotate  the  head  of  the  humerus  upward  and  outward  by  carry- 
ing the  jialm  of  the  hand  downward  and  across  the  patient's  body,  and 
the  bone  will  usually  be  replaced." 

Dislocations  of  the  elbow-.joint  occur  very  fiv(iucntly  in  young 
persons :  50  per  cent,  of  the  cases  are  said  to  Ik-  found  in  persons  under 
fifteen  years  of  age.  This  dislocation  is  therefore  an  exception  to  the 
rule  that  dislocations  are  usually  observed  during  adult  life.  It  is 
generally  the  result  of  direct  violence  by  a  fall  ujion  the  palm  of  the 
hand  or  upon  the  inner  side  of  the  forearm  or  upon  the  olecranon.  It 
has  also  been  ol)served  as  a  residt  of  a  twist  to  the  ulna  in  Mhich  the 
coronoid  process  is  drawn  downward,  inward,  and  backward.  There  arc 
several  varieties,  some  affecting  both  bones  of  the  forearm,  others  the 
radius  alone,  and  still  others  the  ulna.  The  varieties  alfeeting  both 
bones  are  backward,  forward,  outward,  and  inward  ;  those  involving  the 
radius  alone  ave  backward,  fonrard,  ax\d  oxihrard ;  and  that  involving 
the  ulna,  backward. 

Before  describing  tiie  dilfcrcut  dislocations  of  the  elbow-juint  it  is 
very  important  to  a  com]>lete  understanding  of  these  various  injuries  to 
study  the  anatomical  relations  of  the  normal  joint.  The  external  con- 
dyle of  the  humerus,  the  olecranon,  and  the  internal  condyle  of  the 
humerus  should  be  in  a  transverse  line  across  the  posterior  part  of  the 
joint  when  the  forearm  is  extcndrd  u])ou  the  arm.  Any  deviation  from 
this  iKirmal  relation  indicates  a  disliication  or  a  fracture. 

The  signs  and  symptoms  of  dislocation  of  l)oth  bones  of  the  elbow- 


622 


DISLOCATIONS. 


joint  backward,  the  most  frequent  variety,  are — projection  of  the  olecra- 
non l)ack\vard  ;  strcteiiing  of  the  tricc]>s  over  the  lower  exjxised  snrface 
of  the  htuncrns  ;  exposnre  of  the  articulatinji' surface  oi'  the  liiuneriis  ; 
shoi'tcninii'  of  the  forearm;  fixation,  partial  ti<'xion,  and  slialit  pronation 
of  the  forearm;  crepitus,  provided  the  coronoid  ])rocess  is  fi'actured, 
and,  if  it  is  not  fractured,  its  presi'nee  in  the  olecranon  iiissa  (Fig.  144). 

Fig.  144. 


Dislocation  of  radius  and  ulna  backward. 


Fig.  14.5. 


The  signs  and  symptoms  of  dislocation  of  both  bones  forward,  in 
whicli  the  olecranon  is  usually  fractured,  are — lengthenino;  of  the  forearm  ; 
depression  in  front  of  arm  eorrespondins;-  to  the  sigmoid  notch  ;  great 
j)rominence  of  the  condyles  of  the  humerus  ;  depression  behind,  where 
the  olecranon  belongs,  with  aljsence  of  this  process  from  its  normal  place, 
and  its  presence  in  the  trochlear  fossa  on  the  front  of  the  condyles  of 
the  humerus. 

The  signs  and  symptoms  of  dislocation  of  both  bones  outward  or 
to  the  radial  side  (Fig.  145)  are — flexiqn  and  immobility 
of  the  forearm  ;  jironation  of  the  forearm,  with  the  head 
of  tile  radius  upon  the  outside  of  the  joint  and  rotating 
just  beneath  the  skin  ;  and  great  prominence  of  the  in- 
ternal condyle  of  the  humerus.  This  dislocation  is  in- 
complete, since  the  ulna  catches  against  the  external  con- 
dyle. 

The  signs  and  symptoms  of  dislocation  ot  both  bones 
inward  or  to  the  ulnar  side  consist  of  prominence  of  the 
external  condyle,  flexion  of  the  forearm  and  pronation  of 
the  hand,  and  the  presence  of  the  olecranon  jirocess  npon 
the  inner  side  of  the  joint.  This  dislocation  is  not  as 
common  as  the  preceding  one,  on  account  of  the  obliquity 
of  the  articulating  surface,  which  is  higher  internally. 

The  signs  and  symptoms  of  <lislocation  of  the 
radius  backward  are  absence  of  the  head  of  the  radius 
from  its  normal  place  and  its  presence  behind  the  exter- 
nal condyle  beneath  the  skin,  and  fixation  of  the  fore- 
arm. In  this  dislocation  fracture  of  the  external  con- 
dyle often  coexists. 

The  signs  and  sjTmptoms  of  dislocation  of  the  radius 
forward  (Fig.  14(5)  are — flexion  and  .semi-]ironation  of 
the  forearm  ;  head  of  the  railius  upon  the  front  of  the  external  condyle  ; 
a  depression  upon  the  radial  side  of  the  forearm ;  and  inability  com- 


Disloeation  of  the 
head  of  the  radius 
outward. 


SPECIA L  DISLOCA TIOXS. 


62:5 


pletely  to  flex  tlie  forearm,  owing  to  tlie  fact  that  the  head  of  the  hone 
impinges  against  tiie  external  eondvle. 

The  sign  of  dislocation  of  the  radius  outward  consists  of  the  presence 


Fig.  146. 


Dislocation  of  radius  forward. 


of  the  head  of  the  radius  njion  the  outer  side  of  the  external  condyle, 
just  heneath  the  skin,  which   is  stretched  tightly  over  it. 

The  signs  and  symptoms  of  dislocation  of  the  ulna  backward  (Fig. 
147)  are — projection  of  the  ulna  behind,  rotation  of  head  of  radius  in 
its  normal  socket,  crepitus  if  the  coronoid  process  is  fractured,  pronation 
of  the  hand,  and  great  shortening  of  the  forearm  upon  its  ulnar  side. 

Fig.  147. 


Dislocatifii  ul  iln.'  upper  cud  ul  ilic  ulna  liari^uard. 

The  treatment  of  dislocations  of  the  elbow-joint  consists  of  fixation 
of  the  humerus,  flexion  or  extension  of  the  forearm,  and  digital  pressure 
of  the  dislocated  end,  so  as  to  ]iush  it  into  the  joint-socket.  In  case  of 
dislocation  of  both  bones  or  of  the  ulna  alone,  the  extension  should  be 
made  by  gras]iing  firmly  the  forearm  ;  if  of  the  radius  alone,  the  extend- 
ing force  should  be  applied  from  the  hand.  It  is  .seldom  necessary  to 
give  an  ansesthetie,  but  if  it  is  employed  the  reduction  can  be  easily 
eifected.  After  reduction  cold  evajxirating  lotions  of  lead-o])ium  wash 
or  Goulard's  extract,  or  some  stimulating  liniment,  should  be  aj)])licd 
to  the  joint  for  a  few  days  until  all  inflammatory  action  has  subsided. 
In  a  fortnight  gentle  pa.-isive  motion  should  be  employed. 

Di.sLOCATioNs  OF  THE  WRIST-JOINT  are  extremely  rare.  Dupuytren 
has  stated  that  this  dislocation  never  occurs.  This  would  apply  to  intra- 
carpal  dislocations,  but  not  to  I'n-ist-johif  dislocations,  as  shown  below  in 
Figs.  148  and  149.  The  author  has  ol)scrved  four  well-marked  cases 
of  this  injury — one  in  private  pra<'tice  and  three  in  hosjiital  service — 
one  of  which  was  compound. 

The  causes  of  dislocation  (^f  the  wri.'^t-joint  are  falls  upon  the  jialm 
with  the  hand  bent  forward.  The  impacted  fracture  of  the  lower  end 
of  the  radius  simulates  this  injury  to  some  extent. 


624 


DISLOCATrOXS. 


'I'lie  varieties  arc  hdckirdnl  and  Jnnrdnl. 

I'lic  signs  and  symptoms  in  the  buckifurd  variety  consist  of"  a  dorsal 
prominence,  prodnced  hy  the  carpus  overlapping  the  lower  end  of  the 
radius  (Fig.  148) ;  the  iiand  lies  on  a  plane  sujicrior  to  the  forearm,  and 


Dislocation  of  the  carpal  bones  Ijackwarii  (Fergusson). 

the  continuity  of  the  parts  is  thus  destroyed  ;  the  forearm  is  shortened 
from  the  elbow  to  the  tips  of  thi'  fingers;  there  is  absence  of  crepitus, 
and,  if  the  deformity  is  reduced,  tiiere  is  no  tendency  to  return. 

The  signs  and  symptoms  in  the  fonvard  variety  of  dislocation  of 
the  wrist-joint  consist  of  a  palmar  prominence  produced  by  the  carpus 
sliding  up  upon  the  anterior  surface  of  the  radius;  the  hand  is  on  a  plane 
inferior  to  the  forearm  (Figs.  14(1  and  1.50).  The  remaining  signs  arc 
similar  to  those  in  the  backwanl  dislocation. 

The  differential  diagnosis  of  either  of  these  dislocations  from 
Colles's  fracture  is  made  l)y  the  absence  of  the  characteristic  signs  of 
fracture  and  the  disturbed  relation  of  the  styloid  processes  to  the  bones ; 

in  sprains  all  the  characteristic 
signs  of  dislocation  and  fracture 
are  absent ;  in  ganglia,  the  pres- 
ence of  fluid,  ascertained  by  the 
use  of  a  hypodermic  needle,  and 
the  peculiar  deformity  caused  by 
the  fluid  dipping  under  the  annu- 
lar ligament,  are  characteristic-. 

Fig.  150. 


Fig.  149. 


Dislocation  of  the  carpal  bones  forward. 


Dislocation  of  the  carpal  bones  forward. 


The  treatment  consists  in  adopting  the  genei'al  principles  laid  down 
in  reducing  any  di.-ilocatiou  by  e-xtension  and  counter-extension.  After 
the  reduction  is  effected  the  hand  slionld  be  placed  upon  an  antero-pos- 
terior  splint  and  kept  at  rest  for  several  weeks. 


SPECIAL  DISLOCATIONS. 


625 


In  one  case  of  conijKmnd  dislocation  wliicli  the  aiitlior  ha<l  under 
treatment  tlie  ulnar  artery  was  ruptured  antl  gangrene  of  the  hand 
ensued,  -which  conditit)n  led  to  amputation  of  the  forearm. 

DlSLOCATIOX  OF  THE    PROXIMAL    PHALANX    OF  THE    THUMB    OCCUrs 

as  a  result  of  a  blow  or  a  fall  upon  the  distal  end  and  palmar  surface  of 
the  thuml>,  so  as  to  cause  forced  extension. 

There  are  two  varieties,  the  backward  and  the  forirard,  and  the 


Fig.  l.il. 


Fifi.  152. 


Unreduced  dislocation  of  the  thumb  (Ashhurst). 

signs  and  symptoms  are  too  evident  to  require  any  special  description 
(Fig.  lol).     This  is  often  the  nio.st  difficult  dislocation  in  the  body  to 
reduce,    and    also,  at   times,  the    most 
easily  reduced  of  all  di.slocations  (Fig. 
152). 

There  have  been  many  reasons  as- 
signed to  explain  the  occasional  dif- 
ficultv  of  reducing  this  dislocation. 
Erichsen  thinks  that  the  head  of  the 
metacarpal  bone  becomes  locked  be- 
tween the  two  heads  of  the  flexor 
brevis  poUicis ;  Cooper  believed  the 
difficulty  to  lie  <liu'  to  the  presence  of 
six  powerful  muscles  ;  Hey  thought 
that  the  obstacle  to  reduction  lies  in 
the  fact  that  the  head  of  the  bone  is 
constricted  between  the  lateral  liga- 
ments of  the  joint  ;  Dupuytren  held  the 
view  that  the  lateral  ligaments,  which 
normally  arc  parallel,  jire  in  this  injury 
at  rio'lit  angles  to  the  axis  of  the  nieta- 
carpal  bone.  The  infolding  of  the  an- 
terior ligament  and  the  intervention  of  a  sesamoid  bone  between  the  joint- 
surfaces  have  also  been  assigned  as  obstacles  to  reduction. 

The  treatment  consists  in  tlie  application  of  extension  and  tlcxiou  in 
many  different  ways,     ("oopcr  suggested  bending  tlic  tiiunih  toward  the 
jialni  in  order  to  relax  the  flexors,  and  then  a})])lyinga  clove-hitch  to  the 
Vol.  I.— 10 


Dislocatiiin    ef  the   mctacarpo-phalangeal 
joint  of  the  thumb. 


626 


DISLOCATIONS. 


distal  phalanx  ;  Bell  suggested  division  ol'  tlic  lateral  ligaments;  Roser 
recommended  extreme  dorsal  flexion,  with  a  view  to  increase  the  amount 
of  extension.  Various  instruments  have  been  devised,  such  as  tiie 
Indian  puzzle  (Fig.  15;3)  and  [jcvis's  instrument  (Figs.  154  and  155). 


"  Indian  luizzle,"  emijluyei-i  f-jr  the  reduction  uf  dislocations  in  small  joints. 

In  certain  cases,  after  every  method  fails,  a  resection  of  the  head  of 
the  bone  is  indicated     The  author  has  performed  this  operation  in  two 

Fig.  1.54. 


Levis's  instrument  lor  reduction  of  h  dislocation  of  the  lingers  or  the  thumb. 


cases  where,  after  repeated  trials  under  anjesthesia,  reduction  could  not 
be  effected.     The  joint-wound  healed   by  primary   intention,  and    the 

Fig.  155. 


Levis's  instrument  applied  to  the  first  tin^'cr. 

function  of  the  joint  was  so  completely  restored  as  to  afford  no  incon- 
venience to  the  patient. 

Dislocation  of  the  phalanges  often  occurs,  and  is  the  result  of 
mechanical  violence. 

The  signs  and  symptoms  are  too  apparent  to  require  any  special 
description. 

The  treatment  consists  in  reducing  the  diislocation  by  extension  and 
counter-extension,  and  placing  the  finger  on  a  .splint  and  applying  a  few 
turns  of  plaster-of- Paris  bandage  to  keep  the  parts  quiet  until  tiie  ligaments 
are  healed.  It  may  be  necessary  after  tlie  removal  of  the  s])lintto  employ 
gentle  passive  motion  until  the  function  of  the  joint  is  fully  restored. 

Dislocations  of  the  hip  form  about  9  per  cent,  of  all  dislocations. 
The  wide  range  of  motion  which  this  joint  enjoys  ex))lains,  in  a  measure, 
the  frequency  of  this  special  injury  as  compared  with  other  dislocations 
in  the  lower  extremity.  Albert  has  shown  that  the  hip-joint  can  be 
fle.xed  and  extended  to  an  angle  of  140°  if  only  the  bones  and  ligaments 


SPECIAL  DISLOCATIOXS. 


627 


are  attached,  and  abduetidii  and  adduction  at  an  ano-le  of  90°  to  100° 
can  be  produced  under  the  same  conditions.  If  tlie  muscles  are  in 
place,  flexion  is  diminished  to  about  30°,  and  adduction  to  20°.  He 
has  thus  demonstrated  that  extension  and  abduction  are  limited  by  the 
li^raments,  while  flexion  and  adduction  are  limited  by  the  muscles  or  by 
mechanical  obstacles,  such  as  the  limb  meeting-  the  abdomen.  In  regard 
to  age,  cases  have  been  rejiorted  from  the  extremes  of  life,  one  case  at 
six  months  and  another  in  the  ninety-second  year. 

There  are  four  diti'erent  varieties  of  dislocation  of  the  hip.  They 
can  be  classified  according  to  the  frequency  of  occurrence  and  also  by  the 
emplovment  of  a  figiu'e  whicii  illustrates  the  anatomical 
arrangement.  If  a  circle  is  drawn,  a  represents  the  iijj- 
ward  dislocation  on  the  dorsinn  ilii  ;  H,  the  bachrctrd 
variety  into  the  ischiatic  notch  ;  c,  the  doirnward  variety 
into  the  obturator  foramen  ;  and  i),  the  forward  variety 
upon  the  os  pubis.  In  studying  the  varieties  of  disloca- 
tion it  is  well  to  adopt  a  definite  ])lan,  which  can  be  :i]i- 
plied  to  all  the  difTercnt  varictit's. 

The  first  variety  of  dislocation  is  i<jiir(ird,n\n\  forms  about  one-half  of 
all  the  cases.     The  head  of  the  bone  lies  ujion  the  dorsum  ilii  (Fig.  156) 

Fio.  156. 


Dislocation  of  the  femur  upon  the  dorsum  ilii. 

and  upon  or  under  the  gluteus  minimus  muscle.  The  injury  is  usually 
produced  by  a  fall  U])on  the  outer  side  of  the  knee  or  foot  when  the  limb 
is  abducted  and  thrown  forward. 

The  signs  and  symptoms  of  this  dislocation  can  be  best  enumerated 
if  the  surgeon  begins  his  examination  by  first  inspecting  the  toe,  then  the 
foot,  knee,  thigh,  trochanter  major,  limb,  and  gluteo-femoral  fold,  in  the 


(528 


DI.SLOCATIOXS. 


order  mentioned,  from  below  upward.  By  this  plan  he  can  readily  detect 
tile  variety  of  dislocation.  In  this  first  variety  the  toe  is  tnrned  toward 
the  opj)osite  instep  ;  the  foot  is  inverte<l ;  the  knee  is  sliij;htly  flexed,  and 
toiielies  or  is  nearly  in  contact  witli  tiie  n])pcr  maru-in  of  tiie  op]iosite 
patella;  the  thijih  is  rotated  inward,  sligiitly  ticxe(l,  and  addncted  ;  tlie 
trochanter  major  is  more  prominent,  and  is  distinctly  felt ;  tlie  entire 
limb  is  shortened  abont  two  inches;  and  the  gluteo-femoral  fold  is  higher 
than  upon  the  opposite  side. 

Fig.  157. 


Dislocation  of  the  femur  baekward  into  the  ischlatie  notch. 

There  are  only  two  injuries  which  could  possildy  be  mistaken  for  dis- 
location upon  the  dorsum  ilii.  The  first  injury  it^J'racture  of  the  neck  of 
the  thigh-bone,  in  which  crepitus,  mo])ility,  eversion  of  the  foot,  less 
amount  of  sh(n-tening,  less  jn-ominence  of  the  trochanter  major,  and  its 
occurrence  in  an  aged  patient,  are  the  differential  points.  The  second 
injury  is  contuaion  of  the  hip-joint,  in  which  the  absence  of  crepitus,  the 
presence  of  the  head  of  the  bone  in  the  acetabulum,  the  absence  of  short- 


SPECIAL   DISLOCATIONS. 


629 


eninfj,  and  the  tests  made  by  Nelatoii's  lint'  and  Bryant's  triangle  (see 
])a<re  5()7)  form  a  group  of  signs  whicli  serve  to  characterize  the  nature 
of  tile  injury. 

Tlie  second  variety  of  dislocation  is  hcd-iranJ  into  the  isehiatic  notcli 
(Fig.  157).  The  injury  results  from  a  fall  upon  the  knee  or  foot  while 
the  limb  is  in  front  of  the  body. 

Adopting  the  plan  of  descrijrtion  given  for  the  preceding  variety,  the 
toe  is  turned  toward  the  opposite  toe ;  the  foot  is  inverted  ;  the  knee  is 
slightly  tlexed  ;  the  thigh  is  rotated  inward,  flexed,  and  adducted  ;  the 
trochanter  major  is  prominent  and  is  <listinctly  felt,  and  is  nearer  the 
anterior  superior  spinous  process  of  the  ilium;  the  limb  is  shortened 
about  one  inch ;  the  gluteo-femoral  fold  is  higher  than  normal  and  the 
head  of  the  bone  can  be  felt  in  the  notch  if  the  finger  is  introduced  into 
the  rectum  or  the  vagina.  The  two  injuries  that  might  be  mistaken  for 
this  dislocation  are  those  described  under  the  preceding  variety. 

Fig.  158. 


Dihlwi  atiuii  t.f  the  femur  downward  intu  the  obturator  inraiuen. 


The  third  variety  of  dislocation  of  the  hip  is  dowmrani  into  the 
obturator  foramen  (Fig.  158).  The  head  of  the  bone  lies  upon  the 
obturator  externus  muscle.  The  injury  is  caused  by  a  fall  when  the  leg 
is  abducted. 

The  toe  points  downward  and  ibrward  ;  the  foot  points  forward  and 
is  everted  ;  the  knee  is  slightly  flexed  ;  the  thigh  is  slightlv  flexed  and 
abducted;  the  trochanter  major  is  flattened  and  is  nearer  the  mesial  line; 
the  entire  limb  is  lengthened  about  two  inches ;  and  the  gluteo-femoral 
fold  is  obliterated. 


mo 


DISLOCATIONS. 


Tlio  fourth  variety  of  dislocatidii  of  the  liip  \ii  forintrd  upcm  tlic  Imri- 
zontal  jxirtioii  of  the  os  ]>uliis  (Fig.  159).     Tiic  head  of  tiic  hone  lies 


Fio.  159. 


Di.slocatiun  uf  the  femur  forward  upon  the  os  pubis. 

upon  the  outer  side  of  the  femoral  artery  and  al)ove  Poii])art's  ligament. 
The  injury  i.s  produeed  by  a  tidl  when  tlie  limb  is  thrown  backward  and 
behind  the  centre  of  gravity. 

Adopting  again  the  same  plan  of  description,  the  toe  points  outward; 
the  foot  is  eveited ;  the  knee  is  slightly  tle.xed ;  the  thigh  is  rotated  out- 

FiG.  160. 


Reduction  of  dislocation  on  the  dorsum  ilii  (Sir  Astloy  Cooper's  method). 

ward,  slightly  flexed,  and  abducted  ;  the  trochanter  major  is  rotated 
backward  and  has  lost  its  prominence  ;  the  entire  limb  is  shortened 
about  half  an  inch ;  and  the  gluteo-feiiioral  fold  is  obliterated. 


SPECIA  L  DISL  0  CA  TIONS. 

Fig.  101. 


(i:51 


Reduction  of  dislocation  into  the  sciatic  notcli  iSir  A.  I'ouper's  mctliudi. 


Fi<;.  162. 


It",  now,  tlie  first  and  hccoikI  rnritilcs  are  considered  tooetlier,  it  is  evi- 
dent that  tlie  signs  and  symptoms  differ  only  in  deori'e  and  not  in  kind, 
since  in  both  varieties  the  toe  and  foot  are  inverted,  tile  knee  flexed  and 
adducted,  the  thio;h  rotated  inward,  with  siiort- 
ening  of  linih  and  prominence  of  tlie  trochanter 
major,  and  elevation  of  tlie ghiteo-femoral  folds. 

If  the  third  and  fourth  varieties  are  con- 
sidered tojiether,  it  is  evident  that  many  of 
the  signs  and  symptoms  differ  asjaiii  only  in 
degree  and  not  in  kind,  since  in  both  varieties 
the  toe  and  foot  jioint  downward  and  forward 
and  are  everted,  the  knee  is  nearly  straiijht,  and 
the  trochanter  major  flattened.  In  the  doirii- 
trard  dislocation  there  are  two  inches  of  leiioth- 
ening,  while  in  the  bachirard  dislocation  there 
is  half  an  inch  of  shortening.  The  inversion 
of  the  toe  and  foot  in  the  first  and  second  varie- 
ties is  due  to  the  outer  band  of  the  Y-ligament 
of  Bigelow,  since  division  of  this  causes  the 
sign  of  inversion  to  disa]i]K'ar,  as  pointed  out 
by  Bigelow. 

In  considering  the  treatment  of  dislocation 
of  the  hip  the  obstacles  which  prevent  reduction 
must  not  be  overlooked.  They  consist  of  the 
Y-lig;niient ;  the  capsule  which  girds  the  neck 
of  the  bone,  the  small  rent  in  which  pi'c- 
vents  the  free  return  of  the  Ijone  into  the 
joint ;  the  sciatic  ncVve,  which  may  become 
entangled  by  forming  a  loop  around  the  neck 
of  the  bone;  the  obturator  externus  tendon, 
which  becomes  ten.se  over  the  back  of  the 
neck  of  the  bone;  and,  finally,  the  muscles, 
which  often  ciiibrace  the  head  in  a  slit-like  aperture.  The  treatment  by 
manipulation  consists  in  overcoming  by  certain  movements  these  various 
obstacles  to  reduction.     The  leg  is  flexed  upon   the  thigh  to  serve  as  a 


I'islucation  into  tlie  obturator 
foramen. 


632 


DISLOCATIOSS. 


\v\v\-  for  tlie  surgeon  ;  tlic  tliitili  is  tlien  flexed  iipdii  the  pelvis  to  relax 
the  Y-li<;aiiient.  The  entire  liinl)  is  tlien  :ih(hiete(l  and  rotated  outward 
in  the  first  and  second  varieties,  in  order  to  throw  tlie  head  oi'  tiie  thit;h- 
hone  over  the  acctahnhun,  wiiile  in  the  third  and  fourth  varieties  tiie 
entire  liuil)  isadihieted  and  rotated  inward.  After  <'iliier  of  these  move- 
ments has  been  executed,  aeeording  to  tlie  variety  of  disloeation,  the  limb 
should  be  suddenly  raised  in  order  to  throw  the  head  of  the  Ixine  over  the 
margin  of  the  aeetaljuhnn,  after  which  the  limb  sliould  be  extended  in 
its  normal  position.  iJricflv,  tiie  two  joints  are  flexed,  flie  lindj  alxlueted 
and  pulletl  (Uitward  and  lifted,  in  the  first  or  second  variety  ;  or  the  two 
joints  are  flexed,  adducted,  and  ]inslied  inward  and  lifte(l  in  the  third  or 
iiiurth  variety.  Sir  Astlcv  Cooper's  methods  of  reduction  by  extension 
are  shown  in  Figs.  160,  161,  162,  and  163. 

The  results  of  treatment  of  unreduced  dislocation  of  the  hip  have  not 
been  satisfactory.     In  six  cases  reported,  only  two  were  reduced  by  an 

Fig.  16.3. 


la^                             ■                                                                                                            l| 

^ 

>^rNr— ^ 

"xi— ^ 

;^^3^5r^'CF5 , 

/'        iS^ 

i                'il         i                            il-^"     V              \    ^^^^      i            : 

Reduction  of  dislucatiun  on  the  pubes  by  Sir  A.  Cooper '^  method. 


operation,  and  in  one  of  the  two  cases  the  patient  died  as  a  result  of  the 
operation,  and  the  other  patient  suffered  from  caries  of  the  bone. 

Compound  (fisloaifions  of  the  hip  are  extremely  rare,  only  about  a 
dozen  cases  ever  having  been  rep<n'ted.  The  treatment  of  such  an  injury 
must  be  conducted  on  the  lines  governing  the  management  of  compound 
dislocations  in  general. 

Dislocation  of  the  knee  is  a  serious  injury,  on  account  of  the 
damage  sustained  not  onlv  bv  tlie  blood-ve.ssels,  muscles,  ligaments,  and 
cartilages,  but  also  by  the  joint  itself,  which  may  undergo  su])puration 
as  the  result.  Fortunatelv,  it  is  rare,  as  it  occurs  in  less  than  2  per 
cent,  of  dislocations,  owing  to  the  number  and  arrangement  of  the  pow- 
erful ligaments.  The  injury  occurs  as  a  result  of  some  direct,  sudden 
mechanical  violence. 

The  varieties  are — oafinird  (Fig.  164),  burnvd  (Fig.  165),  forward 
(Fig.  166),  backward  (Fig.  167),  and  l)v  rotation.  The  second  and  third 
varieties  are  often  incomplete.  The  dislocation  occurs  fonmrd  in  nearly 
half  the  cases,  and  about  20  per  cent,  of  the  forward  dislocations  are 
compound. 

The  signs  and  symptoms  are  too  apparent  to  rerpiire  any  special 
description.  The  iri-egular  a|>pearance  of  the  knee-joint,  the  unusual 
prominence  of  the  condyles,  tlie  immovably  fixed  position  of  the  joint, 


SPECIAL  DISLOCATIONS. 


633 


the  increase  in  the  antero-posterior  or  lateral  diameters  of  the  joint,  the 
loss  of  parallelism  in  the  two  limbs  in  the  first  and  second  varieties,  or 
great  shortening'  in  the  forward  and  l)ack\\ard  \arieties,  distinguish  the 


Fig.  16-1. 


Fig.  165. 


Subluxation  of  the  head  of 
tlie  tibia  outward. 


Subluxation  of  the  head  of 
the  tibia  inward. 


nature  of  the  injury.  In  dislocation  by  rotation  the  leg  is  twisted  upon 
its  own  vertical  axis  either  inward  or  outward,  the  latter  variety  being 
the  more  frequent.  The  appearance  is  so  characteristic  that  a  description 
of  the  signs  and  symptoms  is  unnecessary. 


Fig.  167. 


Subluxation  of  the  head  of  the  tibia 
forward. 


Complete  dislocation  of  head  of 
the  tibia  backward. 


The  treatment  of  dislocation  of  the  knee-joint  e(insists  of  extension 
of  the  leg,  with  coiinter-e.xtension  from  the  thigh  and  pressure  of  the 
head  of  the  tibia  inward,  outward,  Ijackward,  or  forward,  according  to 


634  DISLOCATIONS. 

the  special  variety.  Care  siiouid  be  taken  to  avoid  hyper-extension  of 
tile  leg,  as  the  popliteal  vessels  might  he  injured.  In  the  dislocation  by 
rotation  the  rethiction  is  easily  effected  by  twisting  the  leg  in  tiie  long 
a.xis  of  the  limb  in  the  opposite  direction,  while  extension  at  the  same 
time  is  nutintaini'd.  jVfter  reduction  of  the  tlislocation  the  entire  limb 
should  be  placed  in  a  plaster-of-Paris  bandage,  and  retained  in  an 
innnovable  position  for  several  weeks.  Passive  motion  should  be 
employed  after  the  removal  of  the  splint,  and  no  active  movement 
allowed  for  another  week  after  the  discontinuance  of  the  splint. 

Compoinul  dift/ocafion  of  the  knee-joint  is  a  most  serious  injury,  owing 
to  the  large  size  and  complicated  structure  of  tiie  joint.  If  the  wound  is 
small  and  nothing  foreign  lias  entered  tiie  joint,  the  aperture  can  be  her- 
metically sealed  with  styptic  collodion  painted  over  a  thin  iilm  of  absorb- 
ent cotton.  The  wound,  including  the  joint,  should  be  dressed  ascptically 
and  the  limb  placed  in  a  plaster-of-Paris  splint.  If  the  wound  is  barely 
large  enough  to  admit  the  finger,  the  joint  should  be  thoroughly  irrigated 
with  warm  bichloride-of-mercury  solutic^n  of  the  strength  of  1  :  10,000, 
prepared  with  distilled  water.  A  counter-  and  dependent  opening  should 
be  made  in  order  to  drain  freely  the  cavity  of  the  joint,  and  after  dress- 
ing the  knee  aseptically  the  conventional  retentive  apparatus  of  plaster 
of  Paris  should  be  applied.  If  the  wound  is  larger  than  is  sufficient 
to  admit  the  finger  antl  the  soft  parts  are  lacerated,  a  jjrimary  resection 
should  be  performed,  provided  the  patient  is  young,  ^itli  healthy  viscera 
and  organs,  and  no  large  vessels  or  nerves  are  injured.  Under  these 
same  conditions  primary  amputation  is  indicated  when  the  patient  is  old, 
feeble,  or  affected  with  visceral  disease,  or  when  the  main  vessels  and 
nerves  are  injured.  Conservative  surgery  can  accomplish  nuich  in 
these  days  in  cases  where  a  few  years  ago  amputation  was  tlie  only 
hope  for  tiie  patient's  life.  In  severe  cases  thrombus  of  the  popliteal 
vessels  has  been  observed,  and  gangrene  resulted,  requiring  immediate 
amputation. 

Dislocation  of  the  semilunar  cartilages  involves  a  sub- 
luxation of  the  cartilage  from  its  normal  position,  Avhich  may  occur 
in  consequence  of  a  sudden  twist  or  wrench  in  elderly  people,  or 
the  dislocation  may  occur  as  a  result  of  chronic  disease  of  the 
joint. 

In  this  injury  there  is  sudden  loss  of  the  joint-function,  attended 
by  excruciating  pain,  which  is  often  so  intense  as  to  cause  the  patient 
to  faint  and  to  fall  to  the  ground.  There  are  no  immediate  character- 
istic signs,  as  far  as  the  joint  is  concerned,  l)ut  tlie  joint  soon  becomes 
swollen  from  effusion  and  the  inflaunnatory  reaction  is  very  great.  This 
dislocation  nuist  not  i>e  mistaken  for  a  loose  cartilage  in  tlie  joint,  which 
is  a  chronic  condition  often  recurring  with  some  of  the  signs  of  disloca- 
tion, only  of  not  so  severe  a  character. 

The  treatment  consists  in  returning  the  cartilage  to  its  normal  posi- 
tion while  the  patient  is  under  tiie  influence  of  an  ansesthetic.  The 
jxitient  should  be  jilaced  u])on  his  iiai-k,  tlie  surgeon's  left  arm  should  be 
passed  under  the  popliteal  space,  and  the  leg  seized  and  flexed  by  an 
assistant.  This  manipulation  under  anaesthesia  separates  the  joint-sur- 
faces, and  the  cartilage  can  be  now  pushed  back  into  its  normal  place  by 
the  surgeon's  right  hand.     After  reduction  the  ice-cap  should  be  placed 


SPECIAL  DISLOCATIONS. 


635 


Fig.  168. 


Apparatus  employed  to  limit  motion  in  disloca- 
tion of  the  semilunar  cartilages. 


Fig.  169. 


over  the  joint  for  twciity-four  lioiirs,  and  then  a  plaster-of-Paris  splint 
applied  over  a  thick  layer  of  absorbent  cotton  to  produce  unitbrni  and 
equable  pressure.  If  the  disloca- 
tion has  a  tendency  to  recur,  the 
surgeon  can  cut  down  upon  the 
loosened  and  displaced  cartilage 
and  suture  it  to  the  bone,  or  even 
excise  it.  This  operation  must  be 
undertaken  with  every  antiseptic 
precaution.  In  cases  where  no 
operation  seems  advisable  some  ap- 
paratus should  be  made  to  limit 
the  amount  of  movement  in  the 
joint  (Fig.  168). 

Dislocation  of  the  patella  occasionally  occurs,  and  forms 
only  about  1  per  cent,  of  all  dislocations.  The  injury  may  be  the  re- 
sult of  mechanical  violence  from  a  blow  or  a  fall  upon  the  side  of 
the  bone,  especially  when  the  knee  is  slightly  flexed,  or  the  dislocation 
may  occur  from  muscular  ai'tion,  or  the  condition  may  be  congenital. 

The  varieties  are  outward,  inward,  vertical,  and  upward.     Any  of 
these  varieties  may  be  complete  or  incomplete.     The  out- 
ward variety  (Fig.  169)  is  the  most  common,  though  the 
natural  plane  of  the  trochlear  surface  Mould  seem  to  favor 
the  inward  variety. 

The  signs  and  symptoms  of  outward  dislocation 
of  the  patella  are  flatness  of  tiie  knee,  tense  condition  of 
the  quadriceps  extensor  muscle,  inability  to  flex  the  knee- 
joint,  and  the  patella  resting  upon  the  external  condyle. 

In  the  imoard  variety  the  signs  and  symptoms  are 
similar  to  the  above,  except  that  the  signs  are  found  upon 
the  opposite  side  of  the  condyle.  This  variety  is  always 
the  result  of  mechanical  violence. 

The  rertical  or  rotary  variety  has  been  observed  upon 
a  few  occasions,  and  is  caused  by  a  sharp  blow  U])on  the 
side  of  the  patella  mIicii  tiic  knee  is  in  the  semi-flexed 
position. 

The  upward  variety  occurs  only  with  rujiture  of  the 
ligamentum    patelhe.       The  accident    is   accompanied   by    considerable 
.synovitis.     The  upward   dislncation   occurs  when  an   attempt  is  made 
to  prevent   one's  self  from  falling  backward,   or  it  may   follow  as  a 
result  of  falling  ujjon  a  liroken  ])iece  of  glass  or  by  a  sabre  cut. 

The  treatment  of  dislocation  of  the  patella  in  the  outward,  inward, 
and  vertical  varieties  consists  in  elevating  the  entire  limb,  so  as  to  relax 
the  quadriceps  extensor  nuiscle,  which  should  be  pushed  toward  the 
patella  while  tliC  limb  is  tlius  hyper-extended.  The  bone  itself  is  now 
pushed  by  means  of  digital  pressure  into  its  proper  position.  Hooks 
have  been  inserted  under  the  skin  to  make  outward  traction,  but  their 
use  is  attended  with  more  or  less  danger.  In  the  upward  variety  the 
ligamentum  patelhe  nuist  be  sutured  to  its  original  point  of  attachment 
to  the  tibia  at  the  place  from  wliich  the  tendon  lias  l)een  torn.  This 
operation  mu.st  be  performed  with  great  care  and  with  every  antiseptic 


Andrews's  case  of 
dislocation     of 


636  DISLOCATIOXS. 

preciiiition,  since  the  close  proximity  to  tiie  knee-joint  niiikes  the  opera- 
tion one  of  more  or  k'ss  gravity.  The  knee  shoiikl  he  placed,  aiter 
reduction,  in  a  plaster-(ji'-Paris  splint.  ^Vf'ter  several  weeks  the  dressing 
can  he  removed  and  an  elastic  knee-cap  applied  over  the  joint,  in  order 
to  maintain  tlu'  jiatella  in  its  proper  position,  and  also  to  att'ord  greater 
security  to  the  patient.  In  the  congenital  variety  a  knee-cap  should  be 
worn,  which  has  a  tendency  to  prevent  the  bone  from  slij>ping  too  far 
out  of  its  place. 

Di.SLOf'ATiox  OP  THE  FIBULA  occurs  as  a  result  of  mechanical 
violence,  muscular  action,  or  disease  or  arrest  of  growtii  of  the  bone,  or 
some  attV'ction  of  an  adjacent  joint,  or  even  by  lengthening  of  the  tibia 
or  tibula  l)y  hypernntrition. 

There  are  two  varieties — one  in  the  upper  part,  at  the  superior  tibio- 
fibular articulation,  and  the  other  in  the  lower  part,  at  the  inferior  fibio- 
fibular  articulation.  In  the  first  variety  the  dislocation  may  be  either 
forward,  backward,  or  upward.  This  variety  is  caused  by  a  blow 
upon  the  head  of  the  fibula,  or  by  a  sudden  contraction  of  the  Inceps 
muscle,  or  by  shortening  of  the  tibia  in  consecpience  of  fracture  of  tlie 
bone.  Dislocation  in  the  lower  end  of  the  fibula  may  be  also  either /or- 
ward  or  backward.  In  this  variety  a  fracture  is  often  associated  with 
the  dislocation. 

The  signs  and  symptoms  are  to(j  apparent  to  require  any  special 
description. 

The  treatment  consists  in  pushing  the  dislocated  end  back  into  its 
place  after  first  relaxing,  by  flexion,  the  muscles  the  contraction  of  which 
would  interfere  with  the  rcducti(in.  If  this  fails,  the  knee  can  be 
extended  with  the  foot  strongly  flexed.  When  the  bone  is  in  its  proper 
place  a  compress  should  be  applied  to  the  dislocated  end,  and  the  entire 
limb  placed  in  a  plaster-of-Paris  bandage  for  several  weeks. 

Dislocation  of  the  ankle-.ioixt  forms  about  3  per  cent,  of  all 
dislocations.  The  injury  is  usually  caused  by  a  fill  ujjon  the  foot,  or 
by  a  force  expended  upon  the  part  of  the  ankle  opposite  to  the  disloca- 
tion.    A  fracture  is  very  often  associated  with  this  dislocation. 

The  varieties  are  outward,  inward,  forward,  backward,  and  upirard. 
The  fibula  is  usually  fractured  in  the  outward,  forward,  and  backward 
varieties,  and  the  tibia  in  the  inward  variety. 

In  the  outward  dislocation  (Fig.  170)  the  foot  is  twisted  and  its 
plantar  surface  is  turned  toward  the  filiula,  the  internal  lateral  ligament 
is  usually  torn,  and  the  inner  malleolus  projects  just  beneath  the  skin. 
This  variety  is  often  mistaken  for  Pott's  fracture. 

In  the  inward  dislocation  the  internal  niallef)lus  is  usually  fractured ; 
the  other  side  of  the  foot  rests  upon  the  ground,  and  tlu'  inner  side  of 
the  foot  is  turned  upward. 

In  the  forward  variety  the  foot  is  very  much  lengthened  and  the 
tibia  rests  upon  the  upper  and  posterior  part  of  the  os  calcis.  This 
form  of  dislocation  is  exceedingly  rare. 

In  the  backward  variety  the  foot  is  very  much  shortened,  the  internal 
lateral  ligament  is  torn,  the  external  lateral  ligament  and  the  fibula  are 
broken,  the  heel  is  very  prominent,  the  toes  point  down,  and  the  end  of 
the  tibia  is  thl•o^^•n  upon  the  scaphoid  and  the  internal  cuneiform  bone. 

In  the  upward  variety  the  tarsal  bones  are  forced  up  between  the 


SPECIAL  DISLOCATIONS. 


637 


tihia  and  fibula,  and  the  ankle-joint  is  very  much  increased  in  its  lateral 
diameter,  while  the  vertical  measurement  of  the  toot  is  much  less  than 
normal. 

The  treatment  consists  in  flexing  the  leg  upon  the  thigh  to  relax 
the  tendo  Achillis,  and  in  making  forcible  but  gradual  traction  upon 


Fig.  170. 


Dislocation  of  tlio  ankle-joint  outward. 

the  foot  in  the  opposite  direction  to  that  from  wliich  the  foot  was  thrust 
at  the  time  of  the  accident.  Division  of  the  tendo  Achillis  may  be 
performed  with  a  view  to  facilitate  the  reduction.  The  foot  should  be 
])]aced  at  once  in  a  plaster-of-Paris  splint,  or  in  lateral  wooden  .splints 
witii  holes  in  the  si(ic  to  correspond  to  the  salient  points  formed  by  the 
two  malleoli.  In  simple  dislocation  of  the  ankle  the  reduction  is  easily 
accomplished,  and  if  the  joint  is  given  sufficient  pliysiological  rest  the 
injury  will  repair  witluiut  any  difficulty. 

Compound  dislocation  of  the  ankle-joint  was  formerly  considered  a 
mo.st  serious  injury.  Even  in  tliese  days,  at  a  time  when  the  technitpie 
of  aseptic  surgery  is  nearly  perfect,  the  management  of  these  cases  is 
often  attended  with  unsatisfactory  results.  The  mortality  in  past  years 
was  very  great,  and  blood-poisoning  was  the  usual  cause  of  death.  At 
the  present  day  this  cause  of  death  has  been  practically  removed,  but 


638  DISLOCATIONS. 

tlie  question  as  to  the  adoption  of  tiie  best  means  of  restoring  the  perfect 
function  of  the  ankle-joint  is  a  most  inij)ortant  one. 

Tiiere  are  certain  Procrustean  rules  the  strict  observance  of  whicth 
has  given  to  the  writer  most  satisfactory  results — first,  as  regards  the  life 
of  the  patient,  and  second,  as  reganls  the  complete  function  of  the  joint. 
These  rules  are  immediate  ase])sis  of  the  entire  limb  ;  thorough  irriga- 
tion of,  and  free  di-ainage  entirely  through  and  across,  the  ankle-joint ; 
the  securing  of  perfect  inuuol)ility  with  plaster  of  Paris;  removal  of  the 
drainage-tube  on  the  third  day,  with  final  irrigation  and  closure  of  the 
drainage  o|)euiiigs  ;  the  employment  of  gentle  passive  movements  and 
massage  at  the  end  of  the  tiiird  week  ;  and  the  free  use  of  the  joint  with- 
out crut(!iies  or  cane  at  the  end  of  the  sixth  week. 

Any  result  other  than  one  attended  with  no  constitutional  disturb- 
ance and  with  complete  restoration  of  the  joint  may  be  called  unsatis- 
factory. The  adoption  of  merely  one  or  several  of  these  rules  will  not 
yield  a  good  result.  Their  adoption  from  the  l)eginning  to  the  end  in  the 
order  mentioned  is  necessary  to  secure  a  satisfac-tory  result.  Perfect 
asepsis  at  the  stiirt  will  not  yield  brilliant  results  unless  faithful  and 
conscientious  attention  is  paid  to  the  subsequent  details.  Each  rule 
must  be  observed  in  proper  sequence  in  order  to  obtain  at  the  end  of 
the  treatment  an  ideal  result. 

Immediate.  Axcpxix  of  the  Entire  Limb. — Too  much  importance  can- 
not be  jilaeed  upon  this  first  rule.  Tiie  extremity  should  immediately  be 
thoi'ougidy  washed  with  an  abundance  of  soap  and  warm  water,  protect- 
ing at  the  same  time  with  iodoform  gauze  the  ojiening  into  the  joint 
durino;  this  ablution.  The  entire  limb  should  be  clcanlv  shaved  with  a 
razor  and  again  washed,  after  which  the  parts  should  be  freely  irrigated 
with  a  1  :  500  solution  of  bichloride  of  mercury.  A  saturated  solution 
of  iodoform  in  ether  should  be  poured  over  all  the  limb.  The  part 
should  now  be  protected  with  towels  wrung  out  in  a  bichloride  solution, 
1  :  2000.  Having  removed  the  wet  towels  ])laced  under  the  leg  during 
the  aseptic  cleansing  of  the  limb,  and  having  substituted  clean  bichloride 
towels,  attention  is  next  directed  to  the  joint  itself. 

Thorough  Irrif/ation  of  the  Joint. — An  irrigator  suspended  a  few  feet 
above  and  filled  with  a  hot  1  :  5000  bicidoride  solution  should  now  be 
used.  The  nozzle  of  the  syringe  should  be  introduced  into  the  joint 
and  all  the  blood-clots  washed  out,  together  with  debris  that  may  have 
entered  the  joint.  A  strong  director  should  be  passed  through  the  joint 
until  its  blunt  end  is  felt  at  a  point  opposite,  and  then  it  should  be  cut 
down  upon  and  the  wound  made  large  enough  to  admit  a  large-sized 
drainage-tube. 

Surgeons  have  been  accustomed  to  drain  the  joint  upon  one  side,  and 
introduce  the  tube  at  the  opening  made  at  the  site  of  the  injury.  This 
is  inadequate  and  insufficient.  A  pocket  upon  the  opposite  side  of  the 
joint  is  formed  in  which  l)lood-serum,  lymph,  and  synovia  collect,  and 
thus  a  nidus  is  formed  for  infection.  Unless  the  joint  is  thoroughly 
irrigated  in  all  its  parts  there  is  danger  of  abscess.  If  a  study  of  com- 
pound dislocation  of  the  ankle-joint  is  made,  the  interesting  fact  is 
observed  that  abscesses  are  subsequently  formed  upon  the  side  of  the 
joint  directly  opposite  to  the  original  opening.  The  time  of  formation 
of  these  abscesses,  and  their  situation  and  character,  point  to  the  fact  that 


SPECIAL  DISLOCATIONS.  639 

their  ilevclopmcnt  Is  due  to  sepsis  originating  within  the  joint.  The 
curious  clinical  fact  tliat  some  time  after  the  original  injury  to  tiie  joint 
an  abscess  forms  upon  the  opp(.isite  side,  and  wiiere  the  tissues  are  all 
sound  and  uninjured,  suggests  at  once  that  the  abscess  is  due  to  sepsis 
and  caused  by  the  ix^tcntion  of  septic  material  in  the  pocket  of  the  joint 
distant  from  the  original  ^V()und.  By  free  and  perfect  tlrainage,  by  anti- 
septic irrig-ation  at  tlie  time  of  the  first  dressing,  and  by  providing  a 
free  outlet  tipon  the  healthy  side  of  the  joint,  we  may  make  sure  that 
no  retention  of  blood  or  lymph  or  synovia  can  take  place,  and  ^\•llerever 
such  perfect  drainage  is  established  the  abscess  is  prevented.  The  abscess 
that  forms  under  these  circumstances  is  prolific  of  evil.  It  sets  up  free 
suppuration  in  the  joint,  and  this  is  followed  by  necrosis,  and  then  resec- 
tion or  amputation  nuist  be  performed  as  a  dernier  ressort  to  save  the 
patient's  life. 

The  next  rule  to  adopt  in  the  management  of  these  cases  is  the  imme- 
diate fixation  by  plaster  of  Paris.  Perfect  immobility  is  essential,  and 
this  can  be  best  secured  by  the  employment  of  the  plaster-of-Paris  band- 
age. The  wound  having  been  covered  by  iodoform  gauze,  and  jiieccs 
of  wet  bichloride  gauze  having  been  jilaced  loosely  over  the  wound  and 
upon  the  foot  and  leg,  a  wet  antiseptic  bandage  should  be  ajiplied  to 
keep  the  loose  dressing  in  place.  Over  this  a  coml)incd  dressing  or 
layers  of  purified  cotton  should  be  rolled,  and  a  bandage  to  keep  the 
dressing  in  place.  A  piece  of  sheet  iron  about  one  inch  in  breadth, 
and  lient  at  the  heel  so  as  to  extend  from  the  toe  down  the  plantar  sur- 
face of  the  foot  over  the  heel  and  up  on  the  posterior  surface  of  the  leg, 
reaching  above  the  knee-joint,  should  be  adjusted.  A  corresponding 
strip  of  sheet  iron  bent  to  fit  the  dorsum  of  the  foot,  the  front  of  the 
ankle,  and  the  anterior  surface  of  the  leg  should  next  be  ajiplied.  Two 
short  lateral  splints  of  the  same  material  should  be  placed  on  either  side. 
The  plaster-of  Paris  bandage  can  now  be  rolled  over  the  splints,  and  a 
light  ])laster  l)andage  applied,  which  now  possesses  great  strength  on 
account  of  the  splints,  but  which  is  not  heavy  or  cumbersome.  At  the 
first  dressing  a  fenestrum  can  be  cut  over  the  \\ounds  in  order  to  with- 
draw the  drainage-tube.  The  leg  can  be  suspended  by  a  Salter  swing, 
which  will  enable  the  patient  to  move  about  in  all  directions  in  bed 
during  the  repair  of  the  wound.  If  there  is  any  difficulty  in  placing 
the  fi)(>t  and  limb  in  proper  position,  the  tcndo  Achillis  can  be  divided, 
aTid  thus  physiological  rest  is  at  once  enforced. 

Still  another  rule  refers  to  the  time  of  removal  of  the  drainage-tube. 
If  the  wound  is  small  and  there  has  been  little  laceration,  the  third  day 
is  the  most  appropriate  time  for  the  entire  removal  of  the  drainage-tube. 
If,  however,  there  is  an  excess  of  discharge  from  it,  the  tube  can  be 
allowed  to  remain  until  the  following  day.  At  this  dressing  on  the  third 
day,  if  it  is  thought  lyest,  for  the  reasons  given,  not  to  remove  the  tube, 
then  it  should  be  irrig-ated,  the  iiozzle  of  the  syringe  being  introduced 
into  one  end  of  the  tube,  and  a  weak  bichloride  solution  passed  through 
it  and  through  the  joint,  and  the  drainage  made  once  more  free. 

It  sometimes  happens  that  after  the  joint  has  lieen  irrigated  the  tube 
can  be  divided  into  two  parts  and  a  short  end  inserted  into  each  of  the 
bilateral  wounds,  and  these  left  in  until  the  following  day.  If  the  tubes 
remain  longer  than  three  or  four  days,  they  excite  irritation  in  the  joint 


640  DISL  0  CA  TIONS. 

and  may  set  \\\>  suppuration.  Ajjain,  the  rnhlter  tulles  beeome  softened 
in  tiiree  days,  and  are  likely  to  tear  aj)art,  owinji'  to  the  tension  prodneed 
l)y  withdrawintr  them  throni;h  tissnes  to  which  they  have  become  afiiiln- 
tinated  by  inflammatory  adhesion.  Finally,  after  three  days  the  tiilx's, 
having  accomplished  the  object  for  which  they  were  employed,  should 
be  removed,  because  they  are  not  intended  to  drain  pus,  but  to  carry  off 
the  products  of  acute  intlanunation  arising  from  the  traumatism  to  the 
joint. 

The  rule  which  relates  to  passive  movements  and  massage  at  the  end 
of  the  third  week  is  an  important  one  to  observe.  Any  movement  of 
the  joint  prior  to  this  date  is  attended  with  danger.  The  parts  are  not 
ready  for  passive  motion  before  three  weeks,  and  an  attemj)t  to  move  the 
joint  prior  to  that  time  will  excite  a  new  inflammation  which  may  lead 
to  supjniration.  If  the  joint  is  not  moved  at  this  time,  the  adhesions 
become  firm,  and  ankylosis  is  certain  to  follow,  and  consequently  the 
function  of  the  joint  is  destroyed.  Shampooing  and  gentle  friction  are 
also  valuable  adjuvants  at  this  period  in  the  history  of  the  injury.  It  is 
to  be  especially  noted  that  the  movement  allowed  to  the  joint  is  not 
active,  but  passive,  and  the  former  should  not  be  permitted  until  six 
weeks  from  the  date  of  the  accident.  The  rule  that  Sir  James  Paget 
has  given  is  here  especially  applicable.  He  taught  that  an  acutely- 
inflamed  joint  with  heat  and  tenderness  in  it  should  be  kept  physiologi- 
cally at  rest,  and  that  a  joint  that  was  stiff  and  partially  ankylosed,  but 
was  free  from  all  inflammatory  action,  should  be  treated  by  passive 
motion  and  massage. 

The  last  rule  refers  to  the  time  when  the  patient  should  begin  active 
movement  in  the  joint.  Active  motion  in  the  joint  is  necessary  at  this 
period  to  excite  the  secretion  of  synovia,  to  release  the  tendons  from  any 
adhesions  due  to  a  thecal  inflammation,  to  disintegrate  fibrous  adhesions, 
to  restore  the  natural  motion  in  the  joint,  and  to  absorb  any  of  the  products 
of  inflammation  or  of  collateral  ledema  and  ecchymoses  in  the  surrounding 
soft  structures.  It  sometimes  happens  that  at  this  stage  swelling  occurs 
in  the  leg  or  in  the  foot  from  the  removal  of  the  plaster  bandage.  This 
is,  however,  only  temporary,  and  will  soon  disappear  njion  the  patient 
walking  about  for  a  few  days.  If  active  motion  is  allo\\'ed  earlier  than 
the  sixth  week,  there  is  danger  of  exciting  new  and  suppurative  inflam- 
mation in  the  joint,  and  a  joint  that  gave  every  prospect  of  becoming 
perfect  in  function  at  the  end  of  the  second  or  third,  or  even  the  fourth, 
week  may  become  totally  destroyed  by  a  too  early  employment  of  motion 
at  a  time  when  absolute  rest  is  imperatively  demanded. 

No  hard-and-fast  rule  can  be  made  as  to  the  amount  of  movement 
that  the  patient  should  be  allowed  to  make.  The  best  guide  is  the  feel- 
ings of  the  patient.  Too  much  exercise  is  as  harmful  as  too  little,  and 
exercise  attended  with  ]xiin  and  fatigue  is  as  injurious  as  movement  of 
the  joint  a  week  after  the  injury.  The  patient  should  be  advised  to 
move  the  joint  l)ut  little  at  first,  and  by  increasing  the  amount  of  move- 
ment daily  perfect  restoration  of  the  joint  can  be  secured. 

Dislocation  of  the  astragalus  occurs  as  a  result  of  falls  from  a 
height  or  of  a  sudden  wrench  or  twist  of  the  foot.  In  these  injuries  the 
ligaments  are  torn  from  their  attachment,  and  the  bone,  being  free,  is 
thrust  out  of  its  position  by  the  tibia,  while  the  foot  is  strongly  flexed, 


SPECIAL  DISLOCATIONS.  641 

extended,  or  inverted.  The  bone  is  dislocated  from  its  relative  position 
between  the  os  calcis  and  the  tibia  and  fibula.  This  injury  must  not  be 
mistaken  for  dislocation  of  the  ankle-joint,  a  description  of  which  has 
alreadv  lieen  given.  In  dislocation  (if  the  astragalus  tiie  bone  not  only  is 
separated  frtmi  the  malleolar  arch,  l)ut  also  from  its  attachments  beneath 
to  the  bones  of  the  tarsus.  In  dislocation  of  the  ankle-joint  the  astrag- 
alus maintains  its  relative  position  to  the  bones  of  the  tarsus. 

The  varieties  are  forward,  backward,  outward,  or  inward,  and  by 
verition. 

In  the  fonrard  dislocation,  wiiich  is  tiic  most  frequent,  the  bone 
becomes  displaced  in  consc(picnce  of  a  fall  or  by  a  twist  of  the  foot, 
which  is  at  the  time  of  the  accident  in  tiie  position  of  full  extension. 
The  astragalus  is  thus  thrown  forward  against  the  astragalo-scaphoid 
lig-amcnt,  which  gives  way  and  permits  the  bone  to  be  thrust  out  of  its 
socket  and  become  lodged  just  beneath  the  skin  on  the  dorsum  of  the 
foot. 

The  signs  and  symptoms  are  tlic  presence  of  the  rounded  head  of 
the  astragalus  ujioii  tlic  dorsum  of  tiic  foot,  the  disappearance  of  the 
normal  landmarks  of  the  joint,  the  complete  loss  of  function,  the  short- 
ening of  the  limb,  owing  to  the  position  of  the  malleoli  near  the  sole  of 
the  foot,  the  prominence  of  one  malleolus  and  the  obliteration  of  the 
other,  M'ith  either  inversion  or  evcrsion  of  the  foot. 

Dixlocntioii  of  the  astrdi/a/iis  Ixtcku-drd  occurs  as  a  rare  injury.  In 
this  varictv  the  bone  is  forcibly  driven  backward  and  either  outward  or 
inward  u]ion  one  or  the  other  side  of  the  tendo  Achillis.  The  inferior 
surface  of  the  bone  lies  upon  the  back  part  of  the  superior  surface  of  the 
OS  calcis.  This  accident  occurs  when  the  foot  is  in  extreme  flexion,  the 
reverse  of  the  position  when  a  forward  dislocation  occurs.  The  injury 
results  from  a  severe  twist  or  wrench  which  causes  rupture  of  the  poste- 
rior fibres  of  the  deltoid  and  external  lateral  ligaments,  as  well  as  of  the 
interosseous  ligament. 

The  signs  and  symptoms  are  the  presence  of  a  bony  prominence 
just  above  the  heel,  with  the  tendo  Achillis  stretched  tightly  over  it 
upon  one  or  the  other  side ;  a  marked  depression  u])on  the  front  of  the 
ankle-joint,  witli  a  prominent  ridge  above  the  fossa,  consisting  of  the 
anterior  articulating  margin  of  the  til)ia  ;  complete  loss  of  function  and 
marked  flexion  of  the  foot  and  innnobility  of  the  ankle-joint. 

Dislocations  of  the  asfrar/alus  outward  and  inicard  occur  with  equal 
frequency,  although  either  variety  is  seldom  observed.  If  the  disloca- 
tion is  complete,  a  fracture  of  the  corrcs]ionding  malleolus  occurs,  and 
the  dislocatiori  is  thus  complicated.  This  act'idcnt  results  from  some 
severe  violence  or  by  a  fall  U])on  the  side  of  the  body  when  the  foot 
is  caught  and  held  firndy  within  tiie  tight  grasp  of  some  object  while 
the  person  is  in  moti'on. 

The  signs  and  symptoms  of  lateral  dislocation  are — presence  of  a 
bony  prominence  upon  one  side  of  the  foot,  with  a  corresponding  depres- 
sion u])on  the  opposite  side  of  the  joint ;  and  crepitus,  as  a  rule,  since 
the  malleolus  upon  the  affected  side  is  fractured. 

Dislocation  of  the  astrrir/ahis  bi/  version  occurs  from  a  sudden  twist 
or  wrench  of  the  foot,  and  the  bone  may  undei'go  rotation  upon  a  hori- 
zontal or  vertical  axis.     During  the  receipt  of  the  injury  the  foot  is 

Vol.  I.— tl 


642  DISLOCATIONS. 

usually  placed  midway  between  Hcxinn  mikI  cxtcnsidn,  and  ron.«efjueiitly 
at  a  riiflit  angle  to  the  leg'. 

Tlu'  signs  and  symptoms  are  cliicHy  neiiative,  since  tliere  are  no 
eharacteristie  ehanges  which  enable  the  surgeon  to  diagnosticate  the  pre- 
cise nature  of  the  injury.  The  diagnosis  must  be  established  upon  the 
sudden  loss  of  motion  in  the  joint,  severe  pain  increased  by  movement 
of  the  foot,  a  rapidly-oeeurring  synovitis,  partial  loss  of  the  normal  con- 
tour of  the  joint,  and,  tinally,  the  existence  of  a  serious  sudden  joint 
affection,  without  any  bony  prominences  to  serve  as  a  guide  to  determine 
the  character  of  the  injury. 

The  treatment  of  dislocation  of  the  astragalus  is  complex,  varying 
somewhat  according  to  the  special  variety  and  the  extent  of  damage 
inflicted.  In  the  incomplete  form  the  dislocation  is  easily  reduced.  In 
the  coni])lete  form  often  great  difficulty  is  met  with  in  attempts  to  rectify 
the  condition.  In  the  forirard  variety  continuous  traction  of  the  foot 
upon  the  leg  must  be  made,  with  the  knee  flexed  to  relax  the  tendo 
Achillis.  It  is  usually  necessary  to  make  this  manipulation  with  tiie 
patient  under  the  influence  of  an  auiesthetic.  If  by  flexion,  extension, 
traction,  and  manipulation  the  bone  cannot  be  returned  to  its  ]iroper 
place,  the  tendo  Aciiillis  and  any  other  rigid  tendon  shoidd  be  divided. 
Tenotomy  usually  permits  the  reduction  of  the  dislocation.  If,  now, 
the  surgeon  is  still  unable  to  return  the  bone  to  its  proper  jilace,  an 
incision  should  be  made  and  the  obstacles  to  I'cduction  removed  if  ])os- 
sible.  If  this  fails,  the  question  of  a  primary  resection,  conservatism, 
or  amputation  arises.  The  operation  of  resection  depends  upon  the  con- 
stitution, age,  and  extent  of  damage  to  soft  jiarts.  If  the  jtatient  is 
young  or  in  adult  life,  witii  healthy  viscera,  and  the  astragalus  is  causing 
pressure  enough  to  produce  slougiiing  of  the  skin,  a  resection  should  be 
made,  since  with  antiseptic  surgery  a  primary  resection  is  far  better  than 
to  wait  until  abscesses  form  and  extensive  caries  follows,  which  neces- 
sarily leads  to  secondary  resection  or  amputation.  If  the  dislocation 
can  be  partially  reduced  and  movement  in  the  joint  is  possible,  and  the 
patient  is  feeble  or  aged,  conservatism  should  be  tiie  line  of  treatment. 
It  is  surprising  how  useful  a  joint  can  l)e  secured  in  these  cases  under 
such  conditions.  If  the  dislocation  is  compound,  the  patient  aged,  and 
the  soft  parts  are  badly  damaged,  Synie's  amputation  is  indicated. 
After  reduction  of  a  dislocation  of  the  astragalus  a  plaster-of-Paris 
splint  should  be  applied  and  the  joint  kept  absolutely  quiet  for  at  least 
six  weeks.  If  a  resection  is  performed,  the  rules  already  given  for 
resections  should  be  adopted,  and  if  amputation  is  re(]uircd,  the  ordi- 
nary rules  governing  this  operation  should  be  observed. 

SubaMmriaJohl  dislocation  consists  of  a  sejiaration  of  the  astragalus 
from  the  scaphoid  and  os  calcis.  In  this  dislocation  the  connection 
between  the  astragalus  and  the  tibia  and  fibula  is  not  disturbed. 

The  varieties  are  forwurd,  Ixicl-irnrd,  oidirard,  and  inwiird.  If  the 
foot  is  dislocated  forirard,  the  head  of  the  astragalus  rests  upon  the 
calcanear  facets  ;  if  hacbcard,  upon  the  dorsd  surface  of  tiie  scaphoid 
or  cuboid  bones;  if  outward,  upon  the  cuboid  lione  ;  if  inward,  u|)on  the 
tuberosity  of  the  scaphoid  bone  (Fig.  171).  These  subastragal()i<l  dislo- 
cations are  caused  b}'  violent  sprains  or  twists  of  the  foot,  and  the  liga- 
ments connecting  the  astragalus   with   the   scaphoid  or  os  calcis  tear. 


SPECIAL  DISLOCATIOys. 


643 


while  the  lisjcaments  between  tlie  ai?tni<;;a]iis  and  tlie   til)ia  and   tibula 

remain  unbroken. 

The  signs  and  symptoms  are  extension  of  the  toot,  whieli  is  k'ngtii- 

ened   beiiind   and   shortened  in  front ;   prominence  of  the  head  of  the 

astragahis,  witii  the  skin  stretched  tiglitly  over  it ;  aversion  or  inversion 

of  the  foot  according  to  the  special  va- 
riety of  the  dislocation  ;  and  great  promi- 
nence of  one  malleolus,  witli  a  partial  ob- 
literation of  the  ]irominence  of  the  oppo- 
site malleolus  and  of  the  astragalus. 

The  treatment  consists  of  extension 
of  the  foot  wiiile  the  knee  is  flexed,  and 
manipulation  of  the  tarsus  during  exten- 
sion.    The  patient  should  be  placed  upon 


Subastragaloid  dislocation 
inward:  5,  sustentaculum 
tali ;  4,  inner  malleolus  ^Du 
Bourg). 


The  same:  1,  head  of  astragalus;  3,  4,  old  cioatrires;  5,  a 
fistula ;  6,  fracture  of  the  fibula  (Du  Bourgi, 


his  back  upon  a  tal>le,  and  the  leg  held  firmly  down,  while  the  foot 
hangs  just  over  the  edge  of  the  table.  If  the  tendons  resist,  they  must 
be  divided.  After  reduction  the  rules  governing  the  management  of 
dislocations  in  general  should  l)e  strictly  adliered  to  in  every  case. 

In  coinpoxnd  mihaxtraf/aloifl  dislocation  a  primary  resection  offers  the 
best  chance  for  the  recovery  of  the  ])atient  and  for  tlie  future  usefulness 
of  the  joint.  If  the  Ijone  projects  and  its  ligamentous  attachments  are 
torn,  the  bone  is  likely  to  become  carious,  which  eventually  leads  to  a 
secondary  resection,  and  the  results  ol)tained  under  these  conditions  are 
not  so  advantageous  as  those  from  a  j)riiiiary  resection  under  improved 
antiseptic  methods. 

Dislocation  of  the  medio-farml  lioiirs:  is  occasionally  observed.  The 
OS  caleis,  scaphoid,  cul)oid,  and  the  cuneiform  bones  have  all  been  dislo- 
cated, either  alone  or  in  conjunction  with  each  other,  and  generall}'  such 
dislocation  is  as.sociated  witli  a  fracture. 

The  signs  and  sjrmptoms  arc  tlie  ]iresence  of  a  dorsal  bony  promi- 
nence, a  depression  corresponding  to  the  situation  of  the  bone,  and  oblit- 
eration of  tlic  plantar  arcli  of  the  foot. 

The  treatment  consists  in  traction  of  the  anterior  jjart  of  tlie  foot 
while  the  heel  is  held  firmly,  and  digital  pressure  to  push  the  bone  into 
its  noi'mal  place.  In  uncomplicated  cases  reduction  has  usually  been 
effected.  In  comjwnnd  dislocation  of  the  medio-tarsal  bones  the  ex- 
tended bone  .should   be  removed  if  the  skin   is  badlv  damaoed  and  the 


644  DISLOCATIONS. 

bone  is  free  from  its  ligiimt'titous  attachmonts ;  otlicrwise  caries  of  these 
articulations  is  likely  to  folK)W  and  necessitate  a  secondary  resection  or 
amputation,  the  ultimate  result  of  which  is  not  so  favorable  as  is  that  of 
a  primary  excision  of  the  dis])laced  bone  under  strict  ase])sis. 

Dislocation  op  the  Jii-yrATAiiSAL  boxes  may  occiu-  as  a  result  of 
a  fall  from  a  hciirht  in  which  the  ])atient  strikes  upon  his  foot,  or  by  a 
heavy  weight  tailing  directly  upon  the  dorsum  of  tiie  foot,  and  in  excep- 
tional cases  even  by  muscular  action.  The  first  metatarsjil  bone  is  more 
frequently  dislocated  than  the  second.  The  third,  fourtli,  and  iifth  are 
usually  dislocated  togethei',  rather  than  singly.  In  some  cases  all  of  the 
metatarsal  bcjues  lui\e  been  sinudtancouslv  dislocated. 

The  signs  and  symptoms  are  too  apparent  to  require  any  special 
description,  since  the  character  of  tlu;  injury  is  at  once  recognized. 

The  treatment  consists  in  traction  of  the  toes  while  the  heel  is  held 
firmly  and  mani])ulative  pressure  exercised.  If  this  fails,  the  bone  can 
be  cut  down  u[ion  and  forced  into  its  position.  Asa  rule,  reduction  is 
most  easily  acconqtlislied.  In  those  few  cases  where  fiihire  to  reduce 
the  bone  was  reported  the  foot  was  fairly  useful,  notwithstanding  the 
unreduced  dislocation.  In  compound  dislocation  with  extensive  bruising 
of  the  soft  parts,  and  with  the  ligaments  badly  torn,  a  primary  resection 
of  the  bone  is  indicated,  and  in  only  very  exccjitional  cases  would  an 
amj)utation  be  performed. 

Dislocation  of  the  phalanges  is  not  often  observed.  The  dislo- 
cation occurs  as  a  result  of  a  fiill  upon  the  toes  or  liy  direct  violence,  as 
in  kicking  some  object  or  stubbing  the  toe  against  a  stone.  The  great 
toe  is  more  often  the  seat  of  dislocation  than  the  others. 

The  signs  and  symptoms  are  too  apparent  to  need  any  description. 

The  treatment  consists  in  traction  of  the  dislocated  toe  while  the  foot 
is  held  tirndy  by  an  assistant.  If  the  reduction  cannot  be  effected  in  this 
way,  some  form  of  traction  forceps,  such  as  are  ust'd  in  case  of  dislocation 
of  the  thumb,  can  be  employed.  If  this  manipulation  fails,  the  bone  can 
be  cut  down  upon  and  another  attempt  made,  and  in  case  of  repeated 
failure  a  primary  excision  of  the  phalanx  should  be  performed,  or  even 
an  amputation  of  the  toe,  especially  if  it  is  any  otiier  than  the  great  toe. 


ANESTHESIA. 

By  h.  c.  wood,  :m.  d.,  ll.  d. 


Ik  considering  the  subject  of  anaesthesia  the  first  question  wliich  arises 
is  as  to  the  choice  of  tlie  antestlictic,  and  in  discussinji'  tiiis  it  seems  to  me 
important  to  cull  attention  briefly,  but  emphatically,  to  the  relations 
which  ought  to  exist  between  clinical  and  experunental  medicine.  The 
value  of  experimental  medicine  to  the  profession  is  very  great,  but  it  is 
entirely  possible  to  go  wrong  in  the  practice  of  medicine  by  attaching  too 
nuich  weight,  or  rather  by  attaching  improper  weight,  to  the  apparent 
results  of  experiments.  The  ultimate  ajtpeal  for  a  final  decision  in  thera- 
penties  nuist  always  be  to  clinical  medicine.  Experiments  upon  the 
lower  animals  are  sometimes  useful  as  guides  in  making  experiments 
upon  human  beings,  but  their  chief  value  is  to  be  found  in  the  intei'pre- 
tation  of  the  results  reached  at  the  bedside.  So  much  attention  has  been 
in  the  past  few  years  given  to  the  experimental  study  of  anaesthetics  that 
there  has  been  danger  of  undervaluing  the  clinical  side  of  the  suliject. 
In  the  present  article  it  is  proposed  to  consider  first  the  clinical,  second 
the  experimental,  evidence. 

In  the  selection  of  an  antesthetic  the  question  of  safety  is  jiaramount. 
One  anaesthetic  may  be  more  convenient  than  another,  less  disagreeable 
to  the  patient,  less  costly  in  time  to  the  surgeon  ;  but  the  question  of 
safety  should  dominate  all  otiiers.  It  should  never  be  forgotten  that  at 
present  we  know  of  no  true  aniesthetic  (for  nitrous  oxide,  for  reasons 
given  hereafter,  scarcely  belongs  to  the  class)  whose  use  is  unaccompanied 
with  danger.  It  is  true  that  recent,  and  perhaps  even  the  older,  medical 
literature  is  flecked  with  the  assertions  of  various  surgeons  that  not  only 
have  they  given  anajstheties  many  hundreds  of  thousands  of  times  with- 
out accident,  but  also  tliat  these  results  have  been  due  to  their  own  indi- 
vidual skill,  and  that  if  their  methods  of  administration  were  adhered 
to  all  the  danger  of  ansesthesia  would  be  overcome. 

There  are  few  things  more  tiresome  in  medical  literature  than  these 
clamorous  outcries  of  conceit  and  vanity.  The  surgeon  who  claims  that 
in  his  hands  anaesthetics  are  free  from  danger,  forgetful  that  death  from 
ana?sthesia  has  occurred  in  the  practice  of  Simpson,  Symes,  Gross,  Agnew, 
Billroth,  and  almost  the  wliole  of  the  list  of  the  world's  greatest  of  sur- 
geons, causes  in  us  some  amusement,  and  still  more  disgust.  Anaesthesia 
produced  in  any  way  is  a  condition  of  danger,  and  the  one  great  hope  of 
safety  on  the  part  of  the  patient  lies  in  the  recognition  of  this  fact  by  the 
anfesthetizer.  Despite  all  precautions,  given  so  many  thousand  anaesthe- 
sias there  will  be  so  many  deaths  from  the  anasthetic  ;  the  oulv  ho])e  is 
by  careful  study  and  by  careful  administration  to  reduce  the  mortality 

645 


646  ANJESTHESIA. 

to  tlif  iniiiiinum  :  tlic  unexpected  will  in  all  ])robability  sometimes  happen 
to  the  end  of  time. 

These  things  being  so,  the  lirst  matter  to  be  decided  is  what  the  clin- 
ical records  reveal  as  to  the  comparative  frequency  of  the  deaths  from 
the  various  anaesthetics.  Fortunately  for  our  purpose,  there  have  been 
recently  published  several  elaborate  studies  of  these  records — studies  so 
complete  that  reliance  upon  them  is  justitialjle  and  further  examination 
of  the  original  records  almost  a  waste  of  time.  The  number  of  sub- 
stances which  have  been  used  by  the  surgeon  to  produce  unconsciousness 
is  quite  large,  yet  three  anaesthetics — nitrous  oxide,  ether,  and  chloro- 
form— stand  out  before  all  others  so  prominently  that  I  shall  first  study 
their  comparative  safety  and  use,  afterward  calling  attention  to  some  of 
the  minor  anaesthetics  as  a  sejiarate  group. 

In  viewing  any  subject  statistically  there  is  always  danger  of  being 
misled  by  fallacies  which  are  too  commonly  recognized  to  be  here  dwelt 
upon  in  detail.  There  are  two  ways  in  which  these  fallacies  may  be  more 
or  less  completely  avoided  :  first,  by  the  selection  of  a  comparatively 
small  cluster  of  observations  made  by  a  single  individual  or  a  small  group 
of  individuals  under  circumstances  as  nearly  uniform  as  may  be  ;  second, 
by  the  gathering  together  of  an  immense  number  of  statistics,  made  under 
all  conceivable  circumstances  by  all  sorts  of  observers — a  collection  in 
which  the  mass  is  so  large  that  there  is  hope  that  mistakes  in  one  direc- 
tion may  be  counterbalanced  by  mistakes  in  the  other.  The  best  recent 
exam])le  of  the  first  method  applied  to  anaesthesia  with  which  I  am 
familiar  is  in  the  table  cdrnpiled  from  the  St.  Bartholomew  Hos]>ital 
Reports  by  Dr.  Geo.  M.  Gould,  editor  of  the  Medical  News  of  Philadel- 
phia. From  1875  to  1890,  inclusive,  in  the  St.  Bartholomew  Hospital 
anaesthesia  was  produced  19,526  times  by  chloroform,  8491  times  by 
ether,  and  12,941  times  by  ether  preceded  by  nitrous  oxide.  The  num- 
ber of  deaths  were  respectively  l-'},  3,  1,  giving  the  mortality  of  chloroform 
as  1  in  1502,  ether  as  1  in  2830,  and  ether  preceded  bv  nitrous  oxide  as 
1  in  12,941. 

Of  statistics  in  which  it  has  been  attempted  to  avoid  error  by  mass 
the  most  recent  and  probably  the  best  is  the  table  prepared  by  Dr.  Gould 
based  upon  that  pul)lished  by  Julliard,  who  in  turn  used  that  of  Compte 
as  a  foundation.  In  this  table  there  are  included  638,461  administrations 
of  chloroform,  with  a  total  of  170  deaths;  300,157  administrations  of 
ether,  with  a  total  ^A'  IS  deaths,  giving  a  mortality  of  chloroform  anaes- 
thesia as  1  in  3749,  and  ether  anajsthesia  as  1  in  16,675. 

The  probable  correctness  of  the  conclusions  reached  by  the  Gould- 
Julliard-Compte  statistics  is  strongly  confirmed  by  the  closeness  vnth. 
which  the  results  coincide  with  those  obtained  from  other  large  statistics. 
Many  years  ago  Dr.  Richardson  of  London  placed  the  jirobaljle  number 
of  deaths  from  chloroform  as  1  in  3000.  In  a  careful  iliscussion  of  the 
statistics  of  anaesthesia  Dr.  H.  ]\I.  Lyman  reached  the  conclusion  that 
the  proportion  of  chloroform  deaths  is  1  in  5860.  In  the  proceedings  of 
the  German  Surgical  Society  in  Berlin,  1891,  sixty-six  European  sur- 
geons reported  nearly  23,000  cases  of  chloroformization,  with  6  deaths, 
giving  a  proportion  of  1   in  3776. 

In  the  report  of  the  Lancet  Commission  for  the  clinical  study  of  ana?s- 
thetics  it  is  attempted  to  get  at  the  proportionate  number  of  deaths  by 


STATISTICS  OF  DEATHS  IN  ANAESTHESIA.  647 

ostimating  the  ])rohalik'  total  ininilKT  (if  an;pstliosias  and  tlio  total  num- 
ber of  reported  deaths.  The  difiieulty  with  this  method  is  obvious: 
only  a  portion  of  tlie  an;estlietic  deaths  are  reported,  and  the  estimation 
of  the  number  of  inhalations  is  nothing  else  than  guesswork.  The  con- 
clusion reached  by  the  eonnnission  is  that  there  liave  been  thirteen  times 
as  many  deaths  from  ehlonifurm  as  from  ether,  and  that  the  number  of 
inhalations  of  ehlorofirm  has  been  six  times  as  great  as  those  of  ether  ; 
which  gives  a  mortality-rate  to  chloroform  more  than  double  that  of 
ether.  These  results  cori'espond  with  the  statistics  of  the  St.  Barthol- 
omew Hospital,  but  are  very  much  more  favorable  to  chloroform  than 
are  the  conclusions  to  be  drawn  from  the  large  mass  of  statistics,  which 
mass  gives  the  proportionate  mortality  about  as  four  and  a  half  to  one. 
I  ])ersonally  believe  that  the  large  statistics,  overwhelming  as  they  are 
in  the  number  of  cases  rejiorted,  represent  as  near  as  can  be  the  true 
state  of  the  case,  and  that  the  surgeon  mIio  administers  chkiroform  faces 
the  fact  that  the  dangers  of  its  use  are  more  than  four  times  those  which 
confront  the  man  who  administers  ether. 

In  strong  contrast  to  the  clinical  results  of  the  use  of  chloroform 
and  ether  is  the  history  of  nitrous-oxide  inhalation.  The  Linicct  Com- 
mission has  collected  seventeen  deaths  as  having  occurred  during  the 
auifsthetic  use  of  the  gas  :  several  of  these  eases  are,  however,  not  fliirly 
attributable  to  the  inhalation,  but  even  if  they  all  be  accepted  as  accu- 
rate reports,  the  mortality  is  scarcely  more  than  nominal.  The  gas  is 
prol)ably  administered  to  seven  or  eight  hundred  thousand  people 
annually  by  lecturers,  dentists,  etc.,  some  of  them  men  of  education, 
others  men  of  ignorance.  In  other  words,  many  millions  of  inhalations 
have  been  given,  many  of  them  by  incompetent  ])crsons,  and  yet  less 
than  two  dozen  cases  of  death  have  occurred  during  the  decades  since  the 
first  administration  of  the  gas.  Dr.  Chas.  M.  Buchanan'  is  probably  not 
far  out  of  the  wav  in  his  conclusion  that  the  mortalitv  of  nitrous-oxide 
inhalation  is  2  ii"i  10,500,000. 

The  startling  ditfcrence  between  nitrons  oxide  and  the  other  agents 
used  leads  nati:rally  to  a  search  for  causes.  The  reason  of  the  difference 
is  that  nitrous  oxide  lies  apart  from  other  aniesthetic  agents  in  being  an 
inert  substance  so  far  as  the  human  organization  is  concerned.  In  the 
production  of  anaesthesia  it  acts  by  shutting  off  the  oxygen  from  the 
blood,  as  is  shown  by  the  fact — established  by  Jolyet  and  Blanche, 
bv  Elihu  Thompson,  and  by  my  own  ex]ieriments — that  an  animal  will 
live  in  nitrogen,  in  hydrogen,  or  even  in  a  vacuum,  as  long  as  in  pure 
nitrous  oxide  ;  and  that,  as  shown  by  myself,-  the  circulatory  phenomena 
of  nitrous-oxide  ansesthesia  are  very  similar  to  those  which  are  caused 
bv  the  inhalation  of  jiure  nitrogen  or  by  mechanical  asphyxia  ;  that,  as 
demonstrated  by  the  French  observers,  coma  is  not  developed  until  the 
oxygen  in  the  blood  is  reduced  to  3  or  4  per  cent.  ;  that,  as  proven  by 
my  own  experiments,'  the  time  recpiired  for  the  jiroduction  of  ana\sthesia 
is  practically  the  same  with  nitrous  oxide  as  with  mechanical  asphyxia  ; 
and  finally,  as  was  shown  in  my  own  experiments,  that  the  addition 
of  3  per  cent,  of  oxygen  doubles  the  time  necessary  for  the  production 
of  ana:;sthesia,   wliilst  the  addition  of  5  ])er  cent,  of  oxygen  more  than 

'  Medical  News,  vol.  l.xii.,  1893.  ^  TItemp.  Gaz.,  1890. 

'  Denial  Cosmos,  1893. 


()48  ANESTHESIA. 

sextuples  the  time  required,  and  S  ptT  cent,  of  oxyircu  indefinitely  post- 
pones the  production  of  eonipiete  ;in;estliesia,  at  least  in  tlie  doii-. 

During  the  use  of  the  true  anajstlictic  there  is  a  ])oison  cireulatinii'  ''^ 
tile  blood,  and  when  an  accident  occurs  time  is  recjuired  for  tlic  removal 
of  this  poison  even  if  no  more  of  tiie  an.estiietic  be  administered.  In 
nitrous-oxide  ansesthesia  there  is  no  poison  in  the  blood,  and  if  at  any 
time  the  partial  arrest  of  function  which  has  been  produced  by  shuttinsj 
off  the  sustaining  oxygen  becomes  too  complete,  tiie  introduction  (tf 
oxygen  into  tlie  l)loo(l  finds  the  nerve-centres  ready  at  once  to  res])ond 
to  their  natural  stimulus.  Unfortunately,  tiie  brevity  of  the  action  of 
nitrous  oxide  prevents  its  general  use  for  the  purjioses  of  the  operating 
sui'geon.  When,  however,  a  tooth  is  to  be  drawn,  an  abscess  to  be 
opened,  or  other  surgical  jjrocedure  involving  but  a  moment  of  time 
gone  through,  nitrous  oxide  is  the  safest  and  best  of  known  auiesthetics. 

The  second  sulj-(|UCstion  whieli  presents  itself  for  studv  in  as  to  the 
method  in  which  aiuesthetics  jn'oduce  death  ;  and  here,  again,  tlie  pro- 
fession is  under  great  obligation  to  the  Lancet  Commission  for  the 
extraordinary  labor  with  which  it  has  searched  out  clinical  records. 
It  has  analyzed  and  tabulated  the  reports  of  384  deaths  during  clilor- 
oformization,  and  has  shown  that  out  of  this  number  in  227  cases  the 
pulse  fiiiled  entirely  before  the  cessation  of  respiration  ;  that  77  times 
cardiac  and  respiratory  action  ceased  simultaneously  ;  and  that  only  in 
80  cases  did  respiration  stop  before  tiie  heart. 

Whatever  the  results  of  experimentation  with  anesthetics  ujxjii  the 
lower  animals  may  be,  it  seems  to  me  absurd  for  any  one  to  claim  that 
in  man  chloroform  does  not  frequently  produce  death  by  an  action  ujion 
the  heart.  In  numerous  cases  of  chloroformization  tiie  action  of  the 
heart  has  been  tested  not  only  Iiy  feeling  tlic  pulse,  Init  also  bv  auscul- 
tation— tested,  too,  witii  a  full  knowledge  on  the  part  of  the  observer 
that  leaders  of  the  profession  have  declared  that  chloroform  never  kills 
by  its  action  upon  the  heart ;  and  yet  in  nearly  four  cases  out  of  five 
it  has  been  noted  that  the  death  came  through  the  heart.  If  clinical 
observations  upon  the  simplest  questions  be  of  any  value  whatever,  the 
conclusion  must  be  tluit  in  the  large  majority  of  cases  cliloroform  death 
has  been  due  to  cardiac  arrest.  It  must  lie  remembered  that  the  average 
intelligence  and  skill  of  the  surgical  observers  who  have  recorded  fatal 
accidents  from  ansesthesia  is  simply  the  general  average  intelligence  and 
skill  of  the  surgical  profession  ;  and  if  these  gentlemen  are  not  to  be 
trusted  to  observe  such  jiatent  phenomena  as  indicate  a  cessation  of  cir- 
culation or  of  respiration,  to  whom  are  we  to  look  for  such  data? 

All  observers,  clinical  and  experimental,  are  in  accord  in  acknowledg- 
ing that  when  chloroform  paralyzes  the  respiration  it  does  so  by  a  direct 
action  upon  the  respiratory  centre  ;  the  matter  still  requiring  careful  dis- 
cussion is  as  to  the  way  of  the  syncopal  deaths. 

When  chloroform  is  given  to  the  lower  animals  there  is  always  after 
the  first  half  minute  of  tlie  inhalation  a  progressive  lowering  of  the 
arterial  jiressure.  Uj)  to  this  point  tiiere  seems  to  be  no  discordancy, 
and  in  the  controversy  which  has  raged  for  the  last  few  years  on  the 
subject  Ave  get  one  firm,  indisputable  point — namely,  that  ether  is  a 
atiiimlant  and  chloroform  a  depressant  to  the  circulation.  For  many 
years  all  observers  have  agreed  that  cliloroform  directly  lowers  the  arte- 


ANESTHESIA.  649 

rial  pi'essure,  but  great  has  been  and  still  is  the  dispute  as  to  the  imme- 
diate mechanism  of  the  tall  which  the  drug-  ])roduccs.  Docs  the  pressure 
come  down  through  the  widening  of  the  blood-])aths  by  a  centric  or 
vasomotor  ]xiralysis,  or  is  tlie  fail  in  jxirt  or  altogx^ther  due  to  an  action 
upon  the  heart '.'  In  other  words,  is  chloroform  a  vasomotor  depressant 
simply,  or  is  it  also  a  cardiac  depressant? 

Sausom  and  Harley  state  that  during  chloroformization  a  spasm  of 
the  small  vessels  can  be  readily  seen  to  occur  in  the  M'eb  of  the  frog. 
Not  until  the  tliird  stage  is  reached,  according  to  these  authors,  do  the 
vessels  relax  into  dilatation.  If  these  observations  be  correct,  chloro- 
form tirst  stinndates  and  afterward  depresses  the  vasomotor  centres.  In 
accordance  with  this  are  the  experiments  of  Gaskell  and  Shore,'  who 
find  that  the  local  application  of  chloroform  to  the  medulla  or  its  injec- 
tion into  the  cerebral  artery  produces  an  immediate  rise  of  blood-pres- 
sure, usually  accompanit'd  l)y  a  slowing  of  the  heart,  this  rise  being  fol- 
lowed by  a  fall  of  pressure  so  soon  as  the  chloroform  is  able  to  diffuse 
itself  over  tlie  circulation.  In  a  further  very  ingenious  series  of  experi- 
ments, Gaskell  and  Shore  connected  the  carotid  artei'ies  and  jugular  vein 
of  an  animal  (A)  with  the  similar  vessels  of  the  second  animal  (B),  so 
that  the  l)rain  of  A  was  fed  exclusively  with  lilood  from  B.  It  is  plain 
that  chloroform  given  to  B  would  reach  the  brain  of  A,  but  woidd  not 
reach  tiic  heart  of  A.  Under  these  circumstances  it  Mas  found  that 
chloroform  administered  to  B  produced  rise  of  pressure  in  A.  In  a 
second  series  of  experiments  the  blood-vessels  of  A  were  so  connected 
with  those  of  B  that  when  chloroform  was  administered  to  B  it  reached 
the  lu'art  of  A  and  all  other  portions  of  the  body  except  the  brain. 
AMien  this  was  the  case,  chloroform  given  to  B  produced  an  innnediate 
fall  of  arterial  pressure  in  A,  without  any  previous  rise.  In  other 
words,  when  chloroform  reached  the  vasomotor  centres,  and  not  the 
heart,  it  caused  rise  of  arterial  pressure ;  when  it  reached  the  heart, 
and  not  the  vasomotor  centres,  it  caused  fall  of  pressure. 

The  only  experiments  with  which  I  am  aecpiainted  to  which  any 
weight  should  be  attached  as  indicating  that  chloroform  primarily  para- 
lyzes the  vasomotor  centres  are  those  published  as  long  ago  as  1S74  liy 
H.  P.  Bowditch  and  ('.  S.  Minot."  In  tiiese  experiments,  which  were 
made  upon  curarized  animals,  "  irritation  of  the  sajihena  nerve  caused 
a  much  less  marked  rise  of  blood-tension  than  when  the  ansesthetic 
was  not  used.  Sometimes  there  was  absolutely  no  rise  of  tension  to  be 
observed,  while  at  other  times  the  rise  was  from  one-third  to  one-half 
that  jiroduced  by  the  same  irritation  on  an  animal  not  subjected  to  the 
action  of  chloroform."  Further,  compression  of  the  carotid  in  the  cldoro- 
formed  aniiuai  did  not  cause  the  customary  spasm  and  rise  of  arterial 
pressure. 

It  must  be  remembered  thi-t  these  experiments  of  Bowditch  and 
]\Iinot  were  made  at  a  time  when  the  importance  of  the  suliject  had  not 
been  fully  realized  ;  that  on  the  carotid  lint  a  single  experiment  was 
made;  and  that  there  was  frequently  in  the  ex])eriments  of  Bowditch 
and  Minot  a  great  rise  of  pressure  following  irritation  of  the  sensitive 
nerve,  though  the  rise  was  not  as  great  as  in  the  normal  dog.  There 
seems  to  be  no  doubt  that  late  in  chloroform-poisoning  there  is  vasV)- 

'  British  Med.  Journ.,  vol.  i.,  1S93.  ^  Boston  Med.  and  Surg.  Jnurn.,  1874. 


().")()  ANESTHESIA. 

iiiotKr  paralysis,  and  it  may  very  well  he  (hat  in  (he  single  carotid 
experiment  of"  Bowditeii  and  Miiiot  the  ciilorofiirmization  had  been 
earried  on  to  tlie  fullest  extent,  whilst  the  rise  of  ])ressiii'e  which 
occurred  in  many  of  their  chloroformed  dogs  when  the  saphena  nerve 
was  irritated  show's  that  at  such  times,  at  least,  the  vasomotor  centres 
\vere  not  ])aralyzed,  though  tht^  arterial  pressure  had  fallen  very  dis- 
tinctly. The  results,  therefore,  of  J5owditch  and  Minot  are  not  in  any 
way  |)roof  of  the  incorrectness  of  the  theory  of  Gaskell  and  Shore,  and 
the  drift  (»f  the  present  evidence  is  to  show  that  chloroform  in  the  earliest 
stayes  of  its  (tction  stimulates  rather  than  depresses  the  vasomotor  centres. 

On  the  heart  itself  chloroform  undoubtedly  exerts  a  steady,  power- 
ful depressing  influence.  Injected  into  the  jugular  vein  (see  also 
MacWilliani's  experiments),  it  instantly  arrests  the  iieart's  action  and 
destroys  its  muscular  irritability.  Even  the  vapor  of  chloi'oforni,  when 
locally  applied  to  the  exposed  heart,  paralyzes  it.'  When  artificial  res- 
piration is  maintained  the  effect  of  chloroform  upon  the  heart  is  very 
apparent.^  By  a  very  ingenious  series  of  experiments  Dr.  MacAYilliam  * 
has  [)roven  that  very  early  in  chloroform  anaesthesia  there  is  a  mai-ked 
diminution  of  the  force  of  the  auricular  and  the  ventricular  beats,  acconi- 
})anied  with  dilatation  of  the  cardiac  chambers,  due  to  the  direct  influ- 
ence of  the  chloroform.  Again,  as  pointed  out  in  the  paper  of  Gaskell 
and  Shore,  even  the  tracings  of  the  Hyderabad  Commission  show  that 
from  the  very  beginning  of  chloroformization  the  excursions  of  the 
heart-beat,  as  portrayed  by  the  Fick  manometer,  get  smaller  and  smaller 
in  the  most  typical  manner.  Indeed,  as  Gaskell  and  Shore  .say,  "  every 
one  Would  agree  with  the  commission  that  tluy  (tlie  ])ulse-waves)  are  of 
the  t)pical  kind  which  would  he  j)roduced  if  direct  \\eakening  of  the 
heart  were  the  cause  of  the  fall  of  blood-pressure  in  chloroform  admin- 
istration." 

Putting  all  the  evidence  together,  it  seems  to  me  to  have  been  com- 
pletely demonstrated  by  jihysiologists — first,  that  chloroform  is  a  direct 
depressant  and  p(irali/zant  to  the  heart-inusclc  or  its  contained  r/an(/lia ; 
second,  that  the  early  fall  of  blood-pressure  which  occurs  in  chloroform- 
ization is  in  great  part,  if  not  altogether,  due  to  this  direct  depression 
of  the  heart. 

This  conclusion  having  been  reached,  attention  is  next  naturally 
directed  toward  a  study  of  the  action  of  ether  upon  the  circulation. 

It  is  firndy  established  by  the  coinciding  results  of  very  many 
experiments  performed  by  various  observers  that  during  etherization 
there  is  usually  a  pronounced  rise  in  the  arterial  pressure,  which  is  com- 
monly maintained  even  through  a  prolonged  narcosis,  and  may  continue 
after  manifest  failure  of  respiration.  Sooner  or  later,  if  the  inhalation 
be  continued,  the  rise  of  arterial  jiressurc  is  followed  by  a  fall,  which 
may  progressively  increase  until  the  manometrical  needle  reaches  almost 
zei'o.  There  have  been  very  few  careful  studies  of  the  details  of  the 
action  of  ether  ujion  the  circulation,  but  such  facts  as  we  have  go  to 
show  that  the  primary  influence  of  the  drug  is  to  stimulate  both  vaso- 
motor centres  and  heart,  and  that  during  the  stage  of  low  pressure  there 
is  depression  of   the  vasomotor  centres   and  also    of  the  heart.     The 

'  Edinburgh  Med.  Joum.,  1842.  •  ^  .loiirn.  Annt.  and  Physiol.,  xiii.,  226. 

'  British  Med.  Joum.,  vol.  iii.,  1890. 


ANESTHESIA.  651 

belief  ill  tiio  primary  stimiilatii)ii  of  tiie  vasomotor  centres  rests  almost 
entirely  upon  the  research  of  Professors  Bowditeh  and  Minot,  made  in 
1<S74,  and  the  snbject  is  well  \\ortliv  of  a  careful  re-study.  There  is 
much  reason  for  the  belief  that  in  advanced  and  profound  ether- 
narcosis  the  blood-vessels  are  alfected  by  the  direct  action  of  the  sub- 
stance upon  their  coats. 

The  clinical  and  physiological  fticts  which  have  thus  far  been  brought 
forward  in  this  paj)er  would  seem  in  themselves,  and  in  tiicir  accordance, 
.<utticieut  to  prove  that  fatal  syncojie  by  direct  effect  of  chloroform  upon 
the  heart  is  the  common  cause  of  chloroform  death,  and  that  ether  is  the 
safer  remedy,  because  it  usually  primarily  stimulates  the  heart.  The 
matter  is  not,  however,  (piite  so  clear  as  it  seems.  It  has  been  within 
the  last  few  years  repeatedly  asserted  by  physiologists  of  repute  that 
neither  ether  nor  yet  chloroform  ever  kills  the  lower  animal  by  cardiac 
paralysis;  or,  in  other  words,  that  it  is  not  possible  to  produce  in  the 
lower  animals  by  iniialation  of  ether  or  chloroform  arrest  of  the  heart's 
action  before  arrest  of  respiration.  This  is,  however,  an  error.  I  have 
been  seeing  chlorofoi'm  death  in  animals  with  great  frequency  for  nearly 
twenty-five  years  in  the  physiological  laboratory,  and  I  have  made  a 
large  number  of  experiments  in  the  most  careful  manner,  and  I  know 
that  in  the  dog  t'hloroform  may  ])roduce  death  liy  a  centric  respiratory 
paralysis,  but  more  commonly  in  my  experiments  has  there  been  a 
simultaneous  or  almost  simultaneous  arrest  of  respiration  and  circula- 
tion, and  occasionally,  and  as  a  rare  phenomenon,  primary  arrest  of  the 
heart  has  occurred.  I  have  seen  the  respirations  continue  for  fully  two 
minutes,  much  of  the  time  full  and  fairly  frequent,  although  there  Avas 
no  blood-movement  whatever  in  an  exposed  carotid  artery  or  any  move- 
ment of  the  heart  that  could  be  detected  l)y  the  hand  f)r  ear. 

Again,  in  exceptional  cases  the  stimulant  influence  of  ether  upon  the 
circulation  is  very  slight  and  transient,  so  that  in  the  physiological 
laboratory  I  have  seen  the  blood-pressure  begin  to  fall  during  an  early 
stage  of  ether  ana'sthesia,  and  I  have  in  one  or  two  cases  seen  a  cardiac 
arrest  jiroduced  by  ether  at  a  time  when  the  respiratory  function  was 
still  active.  As  every  one  knows,  the  Hyderabad  Commission,  the  great 
sujiporter  of  the  exclusiveness  of  respiratory  death,  dei'ived  most  of  its 
authority  from  the  presence  on  it  of  Lauder  Brunton  of  London,  who  in 
a  recent  publication  says  :  "If  we  drive  chlorofVirm  into  the  trachea,  or 
air  very  heavily  loaded  with  chloroform  vapor  into  the  lungs  by  artificial 
respiration,  it  will  be  absorljcd  in  sufficient  (piantitics  to  paralyze  the 
heart."  This  is  a  jiractical  giving  away  of  the  whole  case  of  the  Hy- 
derabad Commission,  at  least  as  I  have  understood  it,  and  as  I  believe 
it  to  have  been  understood  by  the  general  profession.  However  this 
may  be,  it  is  a  confession  that  the  chloroform  death  is  not  of  necessity 
due  to  asphyxia,  so  that  it  mast  be  admitted,  first,  that  both  ether  and 
chloroform  may  kill  the  man  or  the  lower  mammal  either  l)y  arrest  of 
respiration  or  by  syncope  ;  second,  that  syncopal  death  from  chloroform 
is  not  common,  though  it  docs  occur  in  the  lower  animals,  Init  is  not  rare 
in  man  ;  third,  that  the  chief  difference  between  ether  and  chloroform,  so 
far  as  the  mode  of  death  is  concerned,  is  that  that  form  of  death  (synco- 
j>al)  which  is  cranmon  under  the  influence  of  chloroform  is  rare  under 
the  influence  of  ether. 


652  ANESTHESIA. 

Tlio  cardiac  action  of  chloroform  is  evidently  one  cause  of  the  greater 
fatality  of  ciilomforniization,  hut  it  is  not  the  only  reason  why  chloro- 
form kills  so  much  mcjrc  frecjncntly  tlian  docs  ether.  In  my  experi- 
ments upon  the  lower  animals  I  have  noted  that  chloroform  lets  go  its 
hold  much  less  readily  than  does  ether.  This,  I  had  always  supposed, 
was  simply  due  to  the  greater  volatility  of  ether,  but  a  recent  very 
interesting  research  by  Mr.  Julius  Pohl  seems  to  show  that  chloroform 
has  a  primary  attachment,  so  to  speak,  for  the  brain — /.  e.  a  temlcncy  to 
aecunuilation  in  the  brain-tissues.  Mr.  Pohl  found  on  chemical  examina- 
tion tiiat  there  was  much  more  chloroform  present  in  the  brain-tissues 
than  in  the  blood  passing  to  the  brain — a  fact  to  be  explained  only  as  a 
result  of  storing  up  in  the  brain.  It  may  well  be  that  one  cause  of  the 
persistency  of  the  action  of  chloroform  upon  tiie  nerve-centres  is  due  to 
this  tendency  to  escape  from  tlie  blood-vessels  into  the  nerve-tissues. 
Nevertheless,  the  comparative  volatility  of  the  two  ansesthetics  and  the 
comparative  diffusibility  of  their  vajjors  appear  to  be  distinct  elements 
in  the  eomparati\'e  danger  of  their  use.  There  is  very  great  reason  for 
lielieving  that  chloroform  is  less  Ictiial  in  hot  climates  than  in  colder 
I'egions.  The  British  surgeons  of  India  aver  with  one  voice  that  they 
can  administer  it  without  evil  effect.  Tlie  aiisesthetizers  of  the  exti'eme 
southern  or  Gulf  tier  of  American  States  are  almost  equally  urgent  in 
claiming  safety  for  the  use  of  chloroform,  whilst  on  the  continent  of 
South  America  it  is  solely  employed,  again  with  alleged  freedom  from 
ill  effect.  The  only  explanation  of  these  facts  which  seems  to  me  ])lau- 
sible  is  that  at  high  temperatures  cidoroform  va])or  diffuses  very  rajiidly, 
and  consequently  escapes  from  the  blood  and  from  tlie  lungs  witii  extra- 
ordinary rai^idity. 

So  far  as  concerns  what  may  be  considered  the  major  antesthetics, 
the  question  asked  in  the  beginning  of  this  essay  has  n(jw  been 
answered  ;  the  answer  being — first,  that  nitrous  oxide  is  the  safest  and 
best  of  the  amesthetics  when  the  ])urposes  of  the  anaesthesia  admit  of  its 
use — that  is,  when  the  anaesthesia  needs  only  to  be  of  sliort  duration  ; 
second,  that  both  clinical  and  experimental  evidence  agree  in  showing 
that  ether  is  much  safer  than  chloroform,  and,  as  safety  is  under  ordinary 
circumstances  the  one  quality  that  the  surgeon  should  consult  in  the 
choice  of  an  anaesthetic,  no  surgeon  is  justified  in  emploving  chloroform 
unless  it  be  under  certain  peculiar  circumstances  and  for  certain  definite 
reasons  or  purposes. 

Having  arrived  thus  far,  the  next  (juestion  naturally  is,  ^^'hat  arc  the 
circumstances  which  justify  the  use  of  chloroform? 

Before,  however,  discussing  this  it  seems  but  right  to  consider  the 
possibility  of  substituting  for  chlorotbrm  and  ether  some  other  anaesthetic. 
This  leads,  in  turn,  to  the  study  of  \\liat  may  be  termed  the  minor  aiurx- 
thriicfi. 

Of  the  numerous  substances  which  have  been  more  or  less  clamor- 
ously put  forward  as  valuable  anaesthetics,  but  few  require  notice  here. 

Bichloride  of  methylene  was  originally  highly  recommended  by  Dr. 
B.  W.  Richardson  in  18G7,  and  ga\-e  rise  to  a  considerable  controversy. 
In  1883,  j\IM.  Kegnauld  and  A'illejeau  obtained  directly,  through  agents 
accre<lited  l)y  Sir  Spencer  Wells,  tlie  great  advocate  for  the  use  of  methyl- 
ene bichloride,  the  article  employed  as  the  l)icidoride  in  England.     On 


MrXOB  ANJESTHETICS.  653 

careful  elicmical  study  tlicy  fouud  tliat  it  contained  no  liicliloride  of 
methylene,  but  was  composed  of  four  j)arts  of  chloroform  and  one  jiart 
of  methylic  alcohol.  About  this  time,  without  knowing  anything  of 
this  work,  I  had  a  bichloride  of  methylene  of  a  leading  London  chemist 
examined  in  the  chemical  laboratory  of  the  University  of  Pennsylvania, 
and  i'ouud  that  it  was  almost  ])ure  chloroform  ;  so  that  there  can  be  no 
doubt  that  commercial  bichloride  of  uietliyleue  has  been  generally  a  more 
or  less  impure  chloroform. 

In  the  further  studies  of  Eegnauld  and  Villejcau  it  was  determined 
that  chemically-pure  methylene  bichloride  is  very  difficult  and  costly  of 
]n-e])aration,  and  that  when  it  is  given  to  the  lower  animals  as  an  anes- 
thetic it  produces  not  a  qniet  anesthesia,  but  choreic  movements  and 
cpilc]itilbrm  convulsions.  There  are  m\  record  at  least  nine  deaths  ])ro- 
ducctl  by  the  commercial  drug,  and  it  dt)es  not  seem  necessary  further 
to  discuss  the  matter  here  ;  the  bichloride  of  methylene  must  lie  dismissed 
from  the  list  of  practical  anesthetics. 

Pciifal,  a  very  recent  candidate  lor  professional  favor,  is  a  colorless, 
highlv  inflammable  liquid,  boiling  at  100.4°  F.,  which  when  admin- 
istered produces  with  extraordinary  promptness  a  narcosis  which  is  said 
to  disappear  more  rajiidly  than  does  that  caused  by  chloroform  or  ether, 
but  less  rapidly  than  does  that  produced  by  ethyl  bromide.  In  a  study 
of  the  drug  made  by  Dr.  David  Cerna  and  myself  it  w-as  found  that 
pental  anesthesia  in  the  dog  is  always  accompanied  by  a  very  pronounced 
fall  of  the  arterial  pressure,  and  the  conclusion  was  reached  that  the 
remedy  is  a  jiowerfid  di'iiressant  to  the  heart.  Further,  it  has  been  noted 
by  Kleindienst  that  in  man  three  uv  four  days  after  ])ental  narcosis  the 
urine  very  frequently  becomes  heavily  charged  with  albumin,  and  that 
not  rarely  hematuria  or  hemoglobinuria  occurs.  This,  if  confirmed, 
shotdd  put  an  end  to  any  anesthetic  use  of  pental.  Finally,  according 
to  the  only  statistics  upon  the  subject  that  I  know  of — namely,  those  of 
Gurlt — pental  would  appear  to  be  the  most  dangerous  of  all  the  anes- 
thetics in  its  action,  there  having  been  three  deaths  in  the  six  hundred 
reported  narcoses.     The  future  does  not  look  bright  for  pental. 

Efhi/I  bromide  is  a  colorless,  very  volatile  liquid,  which  has  been 
confounded  with  ethylene  bromide  with  fatal  results.  The  substances 
are  essentially  different,  chemically  as  well  as  physiologically.  Ethyl 
bromide  does"  not  solidify  at  32°  F.,  and  has  a  specific  gravity  of  about 
1.49;  ethylene  bromide  has  a  sjiecific  gravity  of  2.16,  and  at  32°  F. 
solidifies  into  a  crystalline  mass.  Ethyl  bromide  was  first  projiosed  as 
an  anesthetic  by  Dr.  Thomas  Nunnelly  in  1 S49,  but  was  not  brought 
earnestly  before  "the  profession  until  1876-77,  when  attention  was  called 
to  it  by  Rabnteau  in  France  and  T>awrence  Turnbull  in  the  United 
States.  Its  influence  is  usually  manifested  a  few  seconds  after  the  begin- 
ning of  an  inhalation,  and  lasts  from  one  and  a  half  to  three  minutes 
after  the  removal  of  the  drug  irom  the  mouth.  A  peculiarity  that  has 
been  rioted  by  several  observers  is  a  tendency  for  sensibility  to  be  lost 
before  consciousness  is  completely  destroyed,  and  Professor  Montgomery 
has  especiallv  noted  that  during  ]>arturition  it  will  do  away  with  most 
of  the  suflering  without  arresting  the  ])ains  or  producing  complete  luicon- 
sciousness.  The  narcosis  is  only  in  rare  instances  accompanied  by  com- 
plete relaxation  of  the  muscles  ;  indeed,  it  appears  to  be  common  for  the 


654  ANAESTHESIA. 

general  niuseiilar  tonus  to  be  greatly  increased.  According  to  Professor 
flolin  H.  Brinton,  muscular  rigidity,  local  spasms,  and  even  gcn(>ral 
tetanus  with  opisthotonos,  occur  so  frequently  as  seriously  to  interfere 
with  the  eni])l<)yment  of  the  drug  as  an  antesthetic,  especially  as  this 
condition  of  muscular  excitement,  when  it  develops  during  a  sui'gical 
operation,  is  attended  liy  great  increase  of  hemorrhage.'  During  narco- 
sis the  corneal  and  pupillary  reflexes  are  usually  preserved,  and  the  eyes 
are  sometimes  wide  open  and  crossed  from  contractions  of  their  muscles." 

Tlie  physiological  action  of  ethyl  bromide  has  been  studied  bv 
Schneider,  by  Abonyi,  by  Thornton  and  INIaxwell,'  and  by  myself. 
Schneider  states  that  the  arterial  ])rcssure  does  not  fall  until  very  late 
in  the  bromide  narcosis,  and  that  death  takes  place  always  through 
arrest  of  the  resjiiration.  In  these  statements  he  is  in  accord  with 
results  obtained  by  Abonyi,^  who  was  not  able  to  detect  any  alteration 
in  the  beat  of  the  exposed  heart  of  the  frog  in  which  narcosis  was  pro- 
duced. On  the  other  hand,  the  experiments  of  Thornton  and  Maxwell 
are  in  agreement  with  my  own,  in  showing  that  the  arterial  pressure 
falls  early  and  increases  steadily  with  a  persistent  inhalation.  In  my 
own  experiments  ethyl  bromide  seemed  to  act  on  the  circulation  simi- 
larly to  chloroform,  although  less  powerfully. 

It  is  possible  that  the  ditterence  of  result  ol)tained  by  physiologists 
has  depended  ujwn  the  ethyl  bromide  being  impure.  In  the  eighth 
edition  of  my  Treafi'^e  on  Thrrapcutirx  it  was  stated  that  clinical  results 
would  jirobably  show  that  ethyl  bromide  is  a  very  dangerous  ansesthetie, 
at  the  time  of  issue  of  the  work  there  being  thi-ee  deaths  reported  as 
occurring  in  a  very  limited  number  of  administrations.^  To  these  cases 
must  be  added  the  death  rejiorted  by  Dr.  A.  Gleieh,''  also  that  recorded 
by  Dr.  Reich.  On  the  other  hand.  Dr.  Gllles  claims  ^  that  there  were 
given  in  Germany  during  three  years  twenty  thousand  administrations 
without  a  single  fatal  result,  and  that  there  is  no  fatal  result  on  record 
in  which  it  has  been  proven  that  a  chemically-pure  bromide  has  been 
administered. 

This  statement  is,  however,  at  present  not  correct.  16  cases  of  death 
from  the  ethyl  bromide  have  been  collected  by  Dr.  Reich,'  and  of  these 
in  5  the  bromide  is  asserted  to  have  been  pure.  It  is  remarkable  that 
out  of  the  7  cases  in  which  any  information  as  to  the  time  of  death  is 
given,  in  only  2  did  death  take  place  during  the  narcosis ;  in  the  other  5 
cases  it  occurred  from  one  to  three  days  after.  In  Dr.  Reich's  case '  the 
inhalation  of  the  bromide  was  followed  by  immediate  and  continuous 
vomiting,  with  development  of  symptoms  similar  to  those  of  acute 
phosphorus-poisoning,  ending  in  death  on  the  seventh  day.  At  the 
auto])sy  the  liver  and  kidneys  were  found  in  active  fatty  degeneration. 
After  the  inhalation  it  was  remembei'ed  that  the  bromide  used  had 
a  faint  yellow  color,  and  it  may  possibly  be,  therefore,  that  the  fatal 
result    was   produced    by  some   decomposition-product.     Early    in    the 

•  Themp.  Gaz.,  viii.  «  Dr.  Gillos  :  Berlin,  klin.  Wochenscli.,  xxix.,  1892. 
3  Therap.  Gaz.,  1892.                  •  Wiener  K/inik.,  1891,  Heft  1. 

*  Therap.  Monatxli.,  vol.  ii.,  1888;  ami  TurnbiiU's  Amesthtsia. 
6  Wien.  kiln.  WoehcHxeh.,  vol.  v.,  1892. 

'  Berlin,  klia.  Wochenaeli.,  vol.  xxix.,  1892. 

8  Wien.  vied.  Wochensck,  1893,  p.  1179.  ^  Op.  cil.,  p.  1226. 


CIRCUMSTANCES  MODIFYING   THE  CHOICE  OF  ANAESTHETIC.     655 

present  year  Koclilcr  reported  a  case'  in  wliieh  the  antesthetic  was 
given  in  small  quantities  with  a  mask,  and  in  whieh,  after  a  very 
transient  and  mild  stage  of  excitement,  the  heart's  aetion  suddenly 
ceased  and  could  not  be  restored,  although  the  breathing  is  said  to  have 
continued  for  a  long  time.  At  the  autojj.sy  the  muscular  structure  of 
the  heart  was  found  in  a  condition  of  extreme  fatty  degeneration. 

Our  present  clinical  experience  certainly  indicates  that  the  use  of 
ethyl  bromide  is  not  devoid  of  dangei',  but  there  seems  to  be  no  sufficient 
reason  for  believing  that  with  an  absolutely  pure  article  the  danger  is 
greater  than  with  chloroform.  The  brevity  of  the  narcosis  and  the 
great  muscular  excitement  which  the  bromide  is  apt  to  provoke  stand 
greatly  in  the  way  of  its  general  use  as  an  auiesthetic,  though  they 
especially  fit  it  for  employment  on  certain  occasions.  It  seems  probable, 
also,  that  it  will  be  found  to  be  a  successful  ]>raetice  to  give  the  ethyl 
bromide  at  the  beginning  of  an  anaesthesia  which  is  to  be  maintained 
by  the  use  of  ether.  There  are  certain  persons,  especially  alcoholics, 
who  greatly  resist  ethyl  bromide,  and  various  surgeons  strenuously  assert 
that  under  these  circumstances  no  attempt  should  be  made  to  force 
anaesthesia  by  this  agent,  but  that  chloroform  or  ether  should  at  once 
be  substituted. 

The  best  method  of  administering  ethyl  bromide  appears  to  be  to  place 
about  two  drachms  in  an  Allis  inhaler  or  upon  the  cone-shaped  napkin. 

Mixed  An.esthetics. — Various  mixtures  of  chloroform  and  ether 
or  alcohol,  chloroform,  and  ether  (the  latter  the  famous  A.  C.  E.  mix- 
ture) have  been  employed  by  surgeons  with  results  \\hich  have  been  on 
the  whole  unsatisfactory.  These  unsatisfactory  results  are  probably,  at 
least  in  part,  dejjendent  upon  the  different  volatility  of  the  different 
agents,  making  it  impossible  to  know  exactly  what  va])ors  are  contained 
in  the  air  breathed  by  the  patient.  All  these  mixtures  are,  in  my 
opinion,  more  dangerous  than  the  individual  drugs  of  which  they  are 
composed,  and  their  use  should  be  eschewed.  The  method  of  producing 
antesthesia  with  one  agent  and  continuing  it  with  another  is  entirely 
different  from  that  which  uses  throughout  a  mixture  of  the  two  agents, 
and  at  present  writing  there  seems  to  be  reason  to  commend  this  form 
of  mixed  anaesthesia.  Thus,  it  is  probable  that  many  of  the  difficulties 
Avhich  attend  the  use  of  ether  can  be  overcome  by  putting  in  the  inhaler 
or  on  the  sjionge  ethyl  bromide  and  then  ether,  the  j)atient  ])assing 
insensil)ly  from  the  bromide  narcosis  into  that  of  ether.  In  England 
it  seems  to  be  a  not  rare  practice  to  commence  antesthetization  with 
nitrous  oxide  and  to  continue  it  with  the  use  of  ether,  and,  if  the  statis- 
tics given  by  Dr.  George  Gould  are  correct,  this  method  of  antesthetiza- 
tion would  seem  to  be  the  safest  known,  for  in  12,941  anaesthesias  so 
produced  in  the  clinic  of  St.  Bartholomew's  Hospital  there  has  been 
1  death.  Certainly 'by  the  primary  use  of  nitrous  oxide  the  feelings  of 
the  patient  and  the  time  of  tiie  surgeon  are  spared. 

Circumstances  wbich  modify  the  Choice  of  Anesthetic. 

In  answering  the  inquiry  as  to  the  circumstances  which  should  modify 
the  choice  of  the  ana;sthetic  by  the  surgeon  I  shall  first  consider  those 

'  CmtraU.f.  Chh:,  2,  1894. 


()")()  ANJESTHESIA. 


iKidifying  circumstances  wliicli  arc  siiii])lcst  and  least  doubtful,  and  shall 


arrange  the  matter  under  eiuuneratcd  licads 


First.  When  ch-cumstances  make  it  practically  impossible  to  obtain 
the  ))uli<ier  antesthetic.  Thus  in  war-times  the  difficulties  of  trans]»(>r- 
tiitidu,  determining  as  they  do  the  niovements  of  great  armies  and  the 
residtsof  great  national  U])heavals,  may  make  it  practically  impossilile 
for  tJie  surgeon  to  have  choice,  antl  certainly  under  such  circumstauces 
it  is  better  to  use  chloroform  than  to  do  without  ansesthctics. 

Second.  When  the  symjitoms  tliemselves  are  of  such  character  as  to 
immediately  threaten  life,  especiaiiy  if  they  at  the  same  time  interfere 
with  the  entrance  of  tlie  auicstiietic  into  tlie  lungs,  the  use  of  clilnrof  irm 
may  well  be  justiiied.  Tlius,  when  a  tetanus  spasm  locks  the  cliest- 
wails  it  often  would  be  folly  to  wait  for  the  action  of  ether,  and  yet  it 
must  be  rememljered  that  under  just  such  circumstances  chloroform  has 
ajiparently  destroyed  life. 

Perhaps  under  this  heading  the  use  of  chlorofoi-m  during  parturition 
should  be  alluded  to.  It  has  Ijccn  stated  from  time  to  time  by  vari- 
ous writers  tliat  tlie  excitement  of  labor  in  some  way  guarantees  the 
system  against  the  deleterious  intluences  of  chloroform,  and  that  it  may 
be  used  with  impunity.  This  is  not  correct :  death  has  occurred  from 
the  ana;sthetic  use  of  chloroform  during  parturition.  Only  infrequent 
occurrences  in  parturition  make  it  necessary  to  use  chloroform.  Ether 
commonly  acts  with  sufficient  jiromjitness,  and  should  tlierefore  be  pi'c- 
ferred.  In  a  violent  case  of  ])uei'j)cral  convulsions,  however,  and  in 
other  critical  conditions,  cldorof)rm  may  be  superior  to  ether.  The 
known  action  of  ethyl  bromide  gives  great  force  to  the  statements  of 
Professor  Montgomery,  that  it  is  especially  valuable  during  labor,  and 
further  trial  of  the  agent  seems  to  be  demanded.  The  obstetrician,  how- 
ever, should  exert  extraordinary  care  to  see  that  he  has  a  ]iure  s]iecimen 
of  the  drug. 

Third.  There  are  certain  bodily  conditions,  iiardly  to  be  sjioken  of  as 
disease,  which  would  exert  some  intluence  in  the  selection  of  the  anaes- 
thetic. In  his  recent  book  Dr.  Frederic  W.  Hewitt  states  that  old 
persons  whose  chests  have  become  rigid  seem  not  to  be  able  to  resjiond 
sufficiently  to  the  demand  made  upon  them  by  ether,  and  tliat  very  old 
persons  hear  chlorof  )rm  practically  well.  In  applying  such  a  principle 
as  tliis  it  must  be  remembered  that  it  is  not  the  years  of  the  person,  but 
the  extent  of  senile  changes  in  his  tissues,  which  should  influence  the 
ansesthetizer.  Dr.  Hewitt  recommends  in  such  cases  the  A.  C.  E.  mix- 
ture ;  if  such  mixture  be  employed,  it  should  always  be  freshly  made  at 
tlie  time  of  its  administration. 

Extreme  obesity  is  another  bodily  condition  in  which  it  is  affirmed 
that  ether  is  often  not  well  boriu',  producing  so  much  excitement  and 
respiratory  irritation  as  to  forbid  its  use.  Under  these  circumstances 
again  Hewitt  recommends  the  A.  C.  E.  mixture,  but  states  that  there 
are  certain  cases  in  which  chloroform  is  necessary  in  order  to  secure  suf- 
ficient tranquillity  of  breathing.  I  have  not  had  practical  experience 
witii  such  patients  of  sufficient  amount  to  be  weighty,  but  my  feeling  is 
tiiat  in  such  cases  ether  should  be  first  tried,  and  then,  if  it  be  not  well 
borne,  chloroform  substituted,  ether  being  again  employed  when  quiet 
anaesthesia  has  been  thoroughly  established. 


CIRCUMSTANCES  MODIFYING  THE  CHOICE  OF  ANESTHETIC.     657 

Fourth.  Various  diseases  contraindicate  the  use  of  an  anesthetic,  and 
also  modify  the  proper  choice  of  tlic  surgeon,  and  I  sliall  therefore  under 
the  present  iieading  consider  diseases  as  general  contraindications  to 
auicsthetics  and  also  as  modifying  the  selection  by  the  surgeon. 

The  diseases  which  are  generally  thought  to  more  or  less  positively 
contraindicate  the  use  of  aniesthetics  are  Organic  Brain  Disease,  includ- 
ing Tumors;  Atheromatous  Conditions  of  the  Vessels;  Diseases  of  the 
Heart ;  Diseases  of  the  Linigs ;  and  Diseases  of  the  Kidneys. 

Brain. — It  appears  from  the  recorded  accidents  of  ansesthesia  that 
the  existence  of  brain  tumor  and  other  organic  forms  of  brain  disease  is 
more  often  the  cause  of  death  tlian  are  att'cctious  of  tlie  heart.  AVhen 
the  brain-arteries  are  believed  to  be  atheromatous,  although  no  positive 
signs  of  organic  brain  disease  are  present,  aniesthesia  should  be  induced 
by  the  surgeon  with  the  greatest  reluctance.  The  cause  of  the  extreme 
danger  in  these  cases  is  probably  the  ease  witli  which  congestions  are 
developed  in  a  brain  which  is  abnormal,  and  the  loss  of  resisting  power 
in  the  resjiiratory  centres  when  weakened  by  disease.  I  know  of  no 
clinical  data  which  will  enable  us  to  decide  which  is  the  safer  agent, 
chloroform  or  ether,  in  the  class  of  cases  now  under  consideration.  The 
greater  power,  however,  of  chloroform  and  the  greater  permanency  of  its 
influence  would  make  it,  a  priori,  probable  that  ether  would  be  the  less 
dangerous  of  the  two. 

Heart  xVnd  Blood-vessels. — Widespread  arterial  atheroma  should 
certainly  give  to  the  surgeon  wlio  desires  aiiicsthesia  much  fear  as  to  the 
result.  The  great  increase  of  the  arterial  pressure  wliich  takes  place  in 
nitrous-oxide  narcosis  may  very  well  endanger  the  integrity  of  an  athero- 
matous vessel.  In  1890  a  gentleman  arose  from  a  dentist's  chair  in 
Philadelphia  after  an  inhalation  of  nitrous  oxide,  staggered,  and  fell  in 
an  apojilexy.  Dr.  F.  A.  Ashford '  reports  a  case  of  a  young  woman  who 
grew  faint  and  dizzy  shf)rtly  after  waking  from  nitrous  oxide,  passed 
into  a  condition  of  disturbed  consciousness,  and  found  when  she  came 
fully  to  iierself  that  her  left  arm  was  useless.  It  apjiears  to  me,  there- 
fore, that  nitrous  oxide  should  never  be  administei'ed  when  there  is 
marked  degeneration  of  the  vessels,  and  that  the  danger  of  its  employ- 
ment woidd  be  especially  great  if  there  should  be  an  aneurism  with 
feeble  walls. 

Ether  certainly  raises  the  blood-pressure,  but  the  amount  of  increase 
is  not  nearly  so  great  as  when  nitrous  oxide  is  given.  Moreover,  in 
the  majority  of  cases  arterial  degeneration  is  associated  with  either 
cardiac  or  renal  disease,  or  very  generally  with  both,  so  that  the  choice 
Ijctwecn  the  two  auiesthetics  is  commonly  to  be  dominated  not  by  the 
atheroma  itself,  but  by  the  coexisting  disease.  In  atheroma  with  failing 
lieart  ctlier  should  certainly  be  ))refcrred  ;  in  atheroma  with  renal  disease 
and  a  normal  heart  chloroform  ivotdd  proI)ably  be  the  safer  agent.  Of 
course  an  apoplexy  may  occur  at  any  time  during  an  antesthesia  :  the 
late  Professor  D.  Hayes  Agnew  once  lost  a  case  during  etherization  ;  and 
in  the  London  Lancet^  is  reported  a  ease  in  which  a  chloroform  inha- 
lation was  followed  by  aphasia,  believed  to  be  due  to  rupture  of  tlie  cere- 
bral vessels. 

Valvular  disease  of  the  heart  is  sometimes  alleged  to  be  a  positive  con- 

^Amer.  Jonm.  Med.  Sei.,  vol.  Ivii.,  1869.  2  yo]  j^  jgyo 

Vol.  I.— 42 


658  ANESTHESIA. 

tniiiidicutloii  to  aiisesthctic  agents.  Wlicn,  however,  the  organic  disease 
does  not  prochice  any  absolute  functional  disarrangement' of"  the  heart, 
and  when  the  heart-muscle  is  in  a  fair  condition  of  health,  ansesthesia 
may  l)e  induced,  provided  the  circumstances  of  the  ease  are  such  as  to 
justify  the  surgeon  taking  a  slightly  increased  risk.  The  key  to  the  situ- 
ation is  not  the  valvular  lesion,  but  the  conchtion  of  the  muscle ;  a  loud 
murmur  usually  depends,  to  some  extent  at  least,  for  its  loudness  upon 
the  character  of  the  valvular  lesion,  but  it  is  also  dependent,  in  part,  for 
its  loudness  upon  the  force  which  drives  the  Ijlood  through  the  diseased 
orifice.  A  loud  murmur  is  therefore,  on  the  M'hole,  not  more  strongly 
contraindicative  of  aniesthesia  than  is  a  feeble  one ;  indeed,  as  the  feeble 
murmur  is  more  commonly  associated  with  feeble  walls,  greater  care  must 
be  exercised  when  such  murmur  exists  than  when  a  loud  bruit  every- 
where forces  itself  upon  the  physician's  attention.  In  all  cases  of  heart 
disease  whenever  it  is  possible  to  avoid  the  use  of  an  anaesthetic  by  the 
emploj'ment  of  cocaine  or  by  other  local  device  this  should  be  done.  No 
condition  of  the  heart  is,  however,  an  absolute  contraindication  to  the  use 
of  the  anaesthetic  ;  under  certain  circumstances  anaesthesia  may  be  pro- 
duced \vhen  the  heart  is  in  advanced  fatty  degenei'ation.  It  must  be 
remembered  that  the  shock  and  nerve-strain  which  attend  a  major  sur- 
gical operation  without  anaesthesia  would  endanger  the  arrest  of  a  fatty 
heart  even  to  a  greater  degree  than  would  anaesthesia  itself,  so  that 
the  question  is,  after  all,  as  to  the  imperativeness  of  the  proposed 
operation. 

In  diseases  of  the  heart  ether  is  usually  preferable  to  chloroform  ;  in- 
deed, when  the  heart  is  very  feeble  or  the  cardiac  muscle  is  degenerated 
the  action  of  chloroform  upon  the  heart  makes  it  a  vei'v  dangerous  remedy. 
In  some  cardiac  cases  there  is  a  widespread  pulmonic  engorgement,  with 
a  tendency  to  exudation  into  the  lung-vessels  and  smaller  bronchial  tubes. 
Under  such  circmiistances  the  local  irritant  action  of  ether  upon  the 
mucous  membranes  is  so  deleterious  that  the  surgeon  is  placed  as  it  were 
between  Scylla  and  Charybdis,  and  may  in  an  individual  case  have  great 
difficulty  in  deciding  what  is  best.  The  A.  C.  E.  mixture  under  these 
circuiustances  may  be  sometimes  selected  with  propriety.  Chloroform  is 
especially  dangerous  when  ortiiopncea  exists ;  it  is  doubtful  whether  in 
such  a  case  its  use  is  ever  justifiable. 

Respiratory  Apparatus. — The  existence  of  severe  organic  disease 
of  the  lungs  seems  to  be  a  less  serious  bar  to  the  use  of  ansesthetics  than 
would  be  naturally  expected.  Of  all  the  chronic  pulmonic  affections, 
probably  emphysema,  associated  as  it  so  frequently  is  with  weakness  of 
the  right  heart,  causes  the  most  solicitude  to  the  ansesthetizer.  The 
irritant  local  action  of  ether  is  an  important  element  when  the  lining 
membrane  of  the  tubes  or  air-vessels  is  seriously  implicated  ;  indeed,  my 
own  opinion  is  very  positive  that  in  some  of  the  deaths  which  have 
occurred  in  persons  with  diseased  kidneys  from  oedema  of  the  lungs 
directly  after  etherization  the  cause  of  death  has  been  the  local  irritant 
influence  of  the  ether.  It  would  ajipear,  also,  that  \\idespread  organic 
changes  in  the  lung  sometimes  so  interfere  with  the  alisorption  of  ether 
that  it  becomes  exceedingly  difficult  to  produce  complete  ansesthesia. 
The  dictum  of  Hewitt,  that  in  extreme  emphysema  in  chronic  bronchitis 
attended    by  expectoration  and  dyspnoea,  and  in  advanced  pulmonary 


CIRCUMSTANCES  MODIFYING  THE  CHOICE  OF  ANESTHETIC.     659 

phthisis,  chloroform  or  some  mixture  containing  chloroform  sliould  be 
employed,  is  worthy  of  great  respect. 

In  all  cases  of  lung  disease  it  is  important  to  remember  tliat  the  more 
chronic  the  disorder  the  less  important  is  it  as  a  contraindication  to  the 
use  of  an  anjesthetic,  and  that  aniesthetics  are  especially  badly  borne  when 
there  is  acute  or  subacute  pulmonary  disease.  Only  nnder  tlie  most 
urgent  circumstances  should  aufesthesia  be  attempted  when  in  an  acute 
pulmonary  disease  the  symptoms  are  of  sufficient  intensity  to  produce 
even  slight  dyspnoea.  In  recent  pleurisy  or  pleuro-pneumonia,  with  any 
embarrassment  of  the  respiration  or  duskiness  of  the  countenance,  anpes- 
thetization  is  attended  with  very  grave  risk. 

In  obstructive  laryngeal  disease,  or  Avhen  contraction  of  the  trachea 
either  from  witiiin  or  without,  or  other  mechanical  obstruction,  jn'oduces 
dyspnoea,  the  greatest  caution  must  be  exercised  in  the  nse  of  the  antes- 
thetic.  Under  these  circumstances  the  chances  of  ether  increasing  the 
mechanical  asphyxia  by  irritating  the  larynx  or  trachea  are  very  great,  so 
tiiat  chloroform  is  preferable  to  etlier  ;  or  chloroform  may  be  employed 
at  first,  and  ether  given  when  the  reflexes  have  been  abolished  bj^  the 
ol)tunding  of  the  nerve-centres.  When  the  laryngeal  obstruction  is  of 
tile  nature  of  a  spasm,  and  not  of  an  organic  change,  the  use  of  the 
an;esthetic  is  free  from  extraordinary  danger ;  but  it  must  be  remem- 
bered that  fretpiently  in  such  cases  there  is  more  or  less  larj-ngeal 
irritation,  so  that  chloroform  is  preferable  to  ether — a  conclusion  which 
is  strengthened  by  the  necessity  M'hich  often  exists  for  the  prompt  action 
of  the  aniesthetic. 

In  certain  cases  the  mechanical  obstruction  may  be  a  tumor  in  the 
mouth  or  other  lesion  above  the  respiratory  tract  proper,  but  if  the 
respiration  be  interfered  with,  the  general  ])rinciples  just  enunciated 
hold  good.  Obstruction  is  a  comparatively  trivial  matter,  but,  when  it 
is  complete,  requires  the  surgeon  by  the  use  of  the  mouth-gag  or  other 
procedure  to  see  that  respiration  througli  the  moutli  is  unimpaired. 

Operations. — The  choice  by  the  surgeon  of  an  anajsthetic  is  often 
modified  by  the  nature  of  the  operation.  In  operations  on  the  parts 
about  the  moutii  it  is  often  difficult  to  maintain  anaesthesia  on  account 
of  the  mechanical  interference  on  the  part  of  the  surgical  operator. 
In  such  cases  the  rule  should  be  for  the  patient  first  to  be  placed 
tlxiroughly  under  the  influence  of  ether,  and,  unless  the  operation  is 
to  be  a  very  lengthy  one,  to  have  been  in  this  condition  for  several 
minutes  before  the  surgeon  begins.  Usually,  when  the  tissues  and 
blood  have  been  thus  surcharged  with  ether,  antesthesia  can  be  main- 
tained by  occasional  whiifs  of  chloroform  given  as  opportunity  is 
afforded  during  the  surgical  procedure.  Indeed,  the  first  anfestlietic 
saturation  is  often  •  sufficient  to  carry  the  patient  througli  the  more 
painful  portion  of  the  surgical  work.  In  tliis,  as  in  otiier  cases,  wlien 
chloroform  is  to  be  administered  to  an  etlierized  patient  it  is  essential  to 
remember  that  often  during  etiicrization  breatiiing  is  heavier  and  deeper 
than  in  the  normal  individual,  so  that  it  is  entirely  possible  inadvertently 
to  give  an  overdose  of  chloroform.  Tiie  frequency  of  the  entrance  of 
blood  into  the  larynx  in  tiiese  cases  comes  rather  within  tiie  ken  of  tlie 
surgeon  than  of  tlie  an;csthetizer,  Init  it  seems  worth  while  to  copy  the 
rules  of  Hewitt,  that  unless  the  convenience  of  the  operator  makes  it 


G(i()  ANJESTHESTA. 

iinpo.ssil)lc,  drainage  fi-oiii  tlie  iiioutli   s^lioiild  be  secured  by  the  patient 
being  placed  in  one  of  tliree  positions  : 

1.  Somewhat  npon  the  side,  with  one  cheek  resting  upon  tiie  pillow, 
and  so  that  tiie  face  is  turned  slightly  downward. 

2.  Sitting  up,  with  the  head  and  shoulders  thrown  Mell  forward,  the 
face  looking  toward  the  couch  or  bed. 

3.  Supine,  with  tlie  head  completely  extended  and  in  the  mid-line. 

As  the  diseases  for  which  the  ojierations  of  cerebral  surgery  are  under- 
taken often  in  themselves  contraindicate  the  use  of  anesthetics,  great 
importance  attaches  to  tlie  question  of  aui^sthesia  in  these  cases.  Pro- 
fessor Victor  Horsley  has  claimed  that  the  hypodermic  injection  of  mor- 
jihine  before  the  use  of  chloroform  is  in  this  class  of  operations  exceed- 
ingly advantageous,  not  simply  because  it  lessens  the  amount  of  the  antes- 
thetic  required,  but  also  because  it  decreases  the  cerebral  congestion  and 
the  consequent  hemorrhage  on  section.  This  practice  has  had  consider- 
able following,  but  its  correctness  seems  to  be  open  to  grave  doubt.  As 
long  ago  as  1863,  Professor  Nussbaum  of  Munich  found  that  when  hypo- 
dermic injections  of  morphine  were  given  during  chloroformization  deep 
sleep  continued  for  a  considerable  time  after  the  withdrawal  of  the  chloro- 
form, and  that  the  jiatient  awoke  without  nausea  or  vomiting.  In  18G9 
the  researches  of  Claude  Bernard  were  published,  and  led  to  the  wide- 
sjjread  trial  of  the  conjoint  use  of  morphine  and  chloroform. 

A-priorl  reasoning  would  render  it  probable  that  anresthesia  woidd 
be  more  easily  produced  and  would  be  more  prolonged  in  the  semi-nar- 
cotized patient  than  in  the  normal  individual,  and  clinical  experience 
has  confirmed  this.  But  in  the  prolongation  of  the  anjesthesia  would 
seem  to  lurk  a  danger.  Certainly,  it  is  but  natural  to  suppose  that 
an  anaesthetic  accident  occurring  in  a  person  who  is  under  the  influ- 
ence not  only  of  a  volatile  and  easily-dissipated  poison,  but  also  of  a 
non-volatile  and  comparatively  permanent  poison,  would  be  far  more 
serious  than  if  the  failure  of  respiration  or  of  circulation  were  the  out- 
come purely  of  an  agent  which  could  rapidly  be  removed.  Several  sur- 
geons have  shown  that  this  reasoning  is  not  devoid  of  practical  support, 
and  a  number  of  cases  have  been  ])ublished  in  which  very  serious  symp- 
toms, or  even  death,  have  occurred  during  the  mixed  narcotism.  In  one 
case  of  Hewitt's  the  importance  of  the  more  persistent  agent  was  shown 
by  the  fact  that  artiticial  respiration  had  to  be  kept  up  continually  for 
four  hours  before  any  automatic  breathing  appeared,  the  fact  indicating 
that,  at  least  in  that  case,  the  morphine  had  more  to  do  with  the  complete 
arrest  of  respiration  than  had  tiie  etiier.  Further,  in  many  persons  the 
use  of  opium  is  prone  to  be  followed  by  excessive  nausea  and  distress; 
in  such  an  individual  the  disagreeable!  after-effects  of  the  anaesthetic 
would  certainly  be  aggravated. 

Some  surgeons  consider  that  ether  should  not  be  used  in  abdominal 
surgery  on  account  of  the  frequent  respiratory  movements,  the  cough, 
the  retching,  the  vomiting,  etc.,  which  sometimes  attend  the  employ- 
ment of  this  anpesthetic,  interfering  with  the  delicate  work  of  the  sur- 
geon. The  presence  of  these  disturbances,  however,  is  usually  an  indi- 
cation of  improper  ansesthesia.  Rigidity  of  the  abdominal  nmscles, 
retching,  and  general  restlessness  are  to  be  overcome  by  the  free  use 
of  the  ansesthetic.     The  disturbances  of  respiration  may  depend  upon 


CIRCUMSTANCES  MODIFYING   THE  CHOICE  OF  ANESTHETIC.     (Kil 

interference  with  the  supply  of  air,  or  perchance  may  be  the  beginning 
asphyxial  symjrtonis  due  to  the  excessive  etherization.  Viok'nt  and 
excessive  vomiting  after  an  abdominal  operation  is  a  serious  thing,  and 
certainly  it  is  more  apt  to  occur  when  ether  has  been  used  than  when 
cidoroform  has  been  employed.  It  can,  ho\\"cver,  be  largely  prevented 
by  proper  method  of  administration. 

Acute  intestinal  obstruction,  with  the  general  colla])se  which  so  often 
accompanies  it  at  the  time  when  the  case  comes  into  the  surgeon's  hands, 
requires  great  care  t)n  the  part  of  the  antesthetizer,  and  some  surgeons 
even  go  so  far  as  to  assert  that  complete  antesthesia  at  such  times  should 
not  he  jtroduced.'  The  pain  and  terror,  however,  of  abdominal  section, 
the  struggles  of  the  patient,  the  general  horrors  of  the  situation,  would 
seem  to  demand  the  use  of  the  antesthetic,  even  though  the  risk  be 
grave.  In  such  a  case,  before  the  anaesthetic  be  given,  the  stomach 
.should  always  be  thoroughly  emptied,  and  no  more  of  the  vapor  should 
be  inhaled  than  is  absolutely  necessary  ;  rapidity  of  action  on  the  part  of 
the  surgeon  becomes  a  matter  of  great  moment,  since  the  danger 
increases  in  almost  geometrical  ratio  with  prolongation  of  the  ansesthesia. 
Ether  is  usually  preferable  to  chloroform,  thougli  not  rarely  it  is  a  very 
good  pi'actice  to  begin  the  ansesthetization  with  chloroform  and  afterward 
maintain  it  with  cth(>r. 

Kidneys. — Writing  in  1890,  Dr.  Lawrence  Turnbull  said  that  "it 
is  of  the  greatest  importance  that  attention  should  be  given  to  tlie  condi- 
tion of  the  kidneys,  and  an  examination  made  of  the  urine  when  an 
ana?sthetic  is  to  be  administered.  Deaths,  unaccountable  otherwise,  are 
due  to  this  cause.  In  diseases  of  the  kidneys,  the  blood  being  loaded 
with  urea,  ana?stheti<'s  almost  invariably  produce  convulsions,  coma,  and 
death."  These  words  of  Dr.  Turnbull  reflect  a  widespread  pn>fessional 
ojjinion.  If,  then,  disease  of  the  kidneys  be  so  strong  a  contraindication 
to  the  use  of  anesthetics,  it  is  necessary  to  examine  very  carefully  as  to 
the  jiroper  choice  of  the  anaesthetic  when,  notwithstanding  the  existence 
of  renal  disease,  ansesthesia  must  be  superinduced.  It  is  jilain  that  two 
distinct  dangers  underlie  the  use  of  the  ansesthetic  in  renal  disease  :  one 
has  to  do  with  the  influence  of  the  drug  upon  the  diseased  kidneys  ;  the 
other  has  to  do  ^vith  the  relations  between  the  secondary  conditions  of 
Bright's  disease  and  the  anaesthetic.  Markedly  atheromatous  arteries 
■contraindicate  nitrous  oxide ;  a  degenerated  heart-muscle  contraindicates 
chloroform  ;  and  it  may  very  well  be  that  sometimes  the  choice  of  the 
surgeon  shoidd  light  uj>on  the  anjesthetic  which  threatens  the  kidneys 
most,  because  it  is  the  least  dangerous  to  those  organs  which  have  become 
sec<mdarily  dis(>ased. 

As  throwing  light  upon  sudden  death  during  antesthesia  it  is  worthy 
of  note  that  in  Dr._  Geo.  B.  ^\^)0(^s  experiments,"  referred  to  lielow, 
several  times  in  dogs  who  were  suffijring  from  nephritis  artificially  ]>ro- 
duced  by  the  use  of  cantharides  or  present  as  the  outcome  of  natural 
disease  sudden  fatal  arrest  of  respiration  occurred,  suggesting  that  there 
may  be  in  urremia  or  uriemic  conditions  a  special  inability  of  the  respi- 
ratory centres  to  resist  the  eflect  of  narcotic  poisons,  and  that  anu>ngst 
the  secondary  effects  of  Bright's  disease  should  be  put  lack  of  resistive 
power  in  the  respiratory  centres. 

'  See  British  Med.  Journ.,  March,  1892.  »  Univ.  Med.  May.,  vi.,  189-1,  p.  802. 


662  ANESTHESIA. 

Ill  attcmptintj  to  dcfidc  as  to  the  clioicc  of  an  anresthctic  for  an  urse- 
inio  patient  it  is  pro[)fr  first  to  stmly  tlic  relations  of  the  aiuestlietic  to 
the  ividneys  themselves.  So  far  as  my  reading  goes,  Dr.  Thos.  A.  Emmet 
of  New  York  was  the  first  to  call  attention  to  the  possibility  of  the  pro- 
duction of  fatal  suppression  of  urine  in  persons  suffering  from  chronic 
Briglit's  disease  by  the  use  of  ether.  In  his  first  experience  complete 
suppression,  and  death  in  three  days  from  nrpemia,  occurred  in  a  patient 
suffering  from  ciiroiiic  cystitis  and  probably  renal  degeneration.  Subse- 
quently  to  this  Dr.  Emmet  is  said  to  have  had  five  such  cases.  Without 
attempting  to  go  over  the  whole  literature  of  the  subject,  attention  may 
be  called  to  the  cases  rcjiortcd  by  Professor  W.  F.  Norris  to  the  Amer- 
ican Ophthalinolooieal  Society  in  1881,  especially  to  the  one  in  -which 
death  in  convulsions  followed  ether  anaesthesia  in  a  child  suflering  from 
fatty  kidneys,  and  in  which  after  death  the  kidneys  were  found  intensely 
congested.  Various  cases  similar  to  these  have  been  pultlished  in  med- 
ical literature,  and  it  does  not  suffice  to  answer,  as  has  been  done,  that 
ether  has  been  frequently  employed  in  Bright's  disease  without  bad 
results. 

It  ought  to  be  possible  positively  to  determine  whetlier  or  not  ether 
is  capable  of  affecting  tlie  secreting  structure  of  the  normal  kidney.  In 
the  British  Medical  JouvnaP  Dr.  Lawson  Tait  records  a  remarkable 
case  in  which,  the  ureters  being  exposed,  it  was  found  that  the  contin- 
uous administration  of  ether  prevented  the  secretion  of  urine,  and  so- 
long  as  the  narcosis  persisted  there  was  no  flow  of  urine.  This  obser- 
vation is  said  to  have  been  repeatedly  confirmed  by  Tait  himself,-  and 
is  of  great  importance  as  evidence  that  ether  does  affect  the  human 
kidney.  It  is  evident  that  experiments  upon  animals  should  be  made, 
in  which,  the  ureters  having  been  exposed  and  canulated,  it  should  be 
determined  whether  these  observations  of  Tait  are  exceptional  or  not. 
Albuminuria  after  ordinary  anresthcsia  is  probably  rare,  but  it  certainly 
does  occur  at  times.  Patein'  found  it  once  in  every  three  cases,  but 
this  is  plainly  much  above  the  average.  In  elaborate  studies  made  in 
the  physiological  laboratory  of  the  Univei'sity  of  Pennsylvania  by  my 
son.  Dr.  Geo.  B.  Wood,^  it  was  found  in  dogs  that  during  ether  anses- 
thesia  the  kidneys  become  markedly  congested,  and  almost  invariably, 
if  the  anfesthesia  had  been  protracted  over  fifteen  minutes  and  the  dog 
then"  killed,  it  was  possible  to  demonstrate  cloudy  swelling  of  the  nuclei 
and  contents  of  the  secreting  cells.  The  cells  of  the  convoluted  tubules 
were  those  primarily  affected,  the  tufts  and  corresponding  tubules  only 
showing  change  when  the  antesthesia  had  been  greatly  prolonged.  It  is 
true  that  Fueter'^  fliiled  to  detect  changes  in  the  kidneys  of  etherized 
dogs,  but  this  negative  testimony  can  hardly  stand  against  the  positive 
evidence  with  specimens  which  were  studied  and  accepted  as  conclusive 
by  Dr.  Guiteras,  professor  of  pathology  in  the  University  of  Pennsyl- 
vania. 

These  researches  and  studies  may  seem  to  the  reader  at  first  sight  to 
demonstrate  that  chloroform  is  the  safer  anaesthetic  when  renal  disease 
exists.  The  case  is  not,  however,  so  clear,  for  it  has  undoubtedly  been 
shown  that  chloroform  itself  has  a  very  deleterious  influence  upon  the 

'  Vol.  ii.,  1880.  "  London  Lancet,  .Ian.,  1883.  '  Paris  Thesis,  1S88. 

*  Loc.  at.  ^  Inaug.  Diss.,  Leipzig,  1888. 


AFTER-EFFECTS  OF  ANESTHESIA.  663 

kidney  strueture.  Alhuminuria  has  been  iioticeil  hotli  in  man  and  in 
animals  after  eiiioroform  nareosis.'  Dr.  Eugene  Fraenkcl  ^  has  fotuKl 
that  after  death  from  protraeted  ehldroform  narcosis  the  seereting  renal 
epithelium  is  in  a  condition  of  profound  degeneration — a  conclusion 
which  he  subsequently  confirms,  stating^  that  the  alteration  in  the  kid- 
ney epithelium  is  never  wanting  after  death  from  prolonged  chloro- 
formization. 

It  would  seem,  therefore,  that  botii  ether  and  chloroform  have  a  dis- 
tinct deleterious  infinence  upon  the  kidneys.  I  am  myself  inclined  to 
believe  that  of  the  two  agents  ether  is  the  more  dangerous  to  the  kid- 
neys, especially  on  account  of  the  great  quantity  which  it  is  necessary 
to  use. 

The  second  division  of  the  present  subject  concerns  the  relation  of 
the  an£esthctic  to  the  secondary  ett'ects  of  kidney  disease.  The  most 
dangerous  of  these  secontlary  effects,  so  far  as  anesthetics  are  concerned, 
and  the  one  which  almost  invariably  occurs  if  the  patient  live  long 
enough,  is  degeneration  of  the  heart-muscle.  It  is  very  evident  that 
when  this  is  present  chloroform  is  a  much  more  dangerous  anjesthetic  than 
is  ether  ;  indeed,  under  such  circumstances  the  danger  from  chloroform 
grows  extreme  <lirectly  as  the  cardiac  lesion  deepens.  The  action  of  ether 
upon  the  secondary  diseased  tissues  of  the  body  in  Bright's  disease  does 
not  seem  to  me  in  any  way  especially  deleterious.  When,  however,  the 
condition  of  the  body  is  such  that  there  is  tendency  to  the  jirodnction 
of  oedema  of  the  lungs  or  to  the  filling  up  of  the  small  tubules  of  the 
lungs  with  watery  secretion,  ether  is  highly  dangerous.  I  believe 
myself  that  in  a  number  of  cases  death  has  under  such  circumstances 
resulted  from  the  sudden  outpouring  of  serum  provoked  by  the  local 
irritant  action  of  the  ethereal  vapor. 

From  what  has  been  said  it  is  plain  that  the  selection  of  an  anaesthetic 
to  be  used  in  a  case  of  Bright's  disease  is  a  matter  of  grave  responsibility, 
and  must  be  based  upon  a  consideration  of  all  of  the  features  of  the  indi- 
vidual case.  If  there  be  no  secondary  lesions,  chloroform  is  probably 
safer  than  ether ;  if  there  be  secondary  lesions,  especially  secondary 
lesions  affecting  the  heart,  ether  may  well  be  safer  than  chloroform.  In 
doubtful  cases  my  own  practice  has  been  to  commence  the  ansesthesia 
Avith  ether,  and  when  the  stimulant  effect  of  the  ether  upon  the  heart 
has  become  manifest  to  use  chloroform,  believing  that  in  this  way  the 
least  possible  strain  is  put  upon  the  heart  and  the  kidneys. 

After-effects  of  Anesthesia. 

In  discussing  the  choice  of  an  ansesthetic  I  have  refrained  from  any 
aUusion  to  the  after-effects  of  these  agents,  for  the  sufficient  reason  that 
our  knowledge  is  at  present  so  imperfect  that  it  can  scarcely  lie  applied 
with  safety.  It  is,  however,  necessary  to  show  that  the  matter  is  of  much 
more  serious  import  than  is  generally  sup]iosed.  The  subject  is,  of  course, 
beset  with  great  difficulties  :  it  may  be  almost  impossible  to  decide  how 
far  any  sequela;  which  may  follow  an  operation  ai'e  due  to  the  emotional 
strain  which  ])reccdes  and  follows  the  work  of  the  surg(!on,  to  the  ope- 

'  See  H.  C.  Wood's  Therapeutics,  9th  cd.,  p.  149. 

'  Virchmifs  Archiv,  Bd.  127,  1892.  »  Virchov^s  Archiv,  Bd.  129,  1892. 


G(i4  ANESTHESIA. 

ratiuii  itself,  to  tlie  ansestlietic,  or  to  extraneous  causes.    Among  the  after- 
effects of  antesthesia  various  writers  place  insanity. 

Mental  Disturbance. — There  can  be  no  doubt  but  tliat  confusional 
insanity  often  follows  a  surgical  operation,  but  it  is  by  no  means  certain 
that  the  antesthetic  has  any  <'ausal  connection  with  the  cerebral  disturb- 
ance. It  is  affirmed  that  in  some  cases  symptoms  of  mental  aberration 
have  developed  immediately  after  an  anaesthesia.  Dr.  Geo.  H.  Savage' 
records  a  case  in  which  violent  delirium  with  insensibility  of  the  con- 
junctiva, ending  in  three  weeks  in  complete  dementia,  followed  in  a 
chronic  (Irinker  innnediately  upon  nitrous-oxide  inhalation.  Such  a  case, 
however,  obviously  separates  itself  from  one  in  which  a  true  aniesthetic 
lias  been  enqiloyed.  It  is  entirely  jiossible  that  during  the  venous  stasis 
of  the  artificial  asphyxia  rupture  of  small  vessels  may  occur  or  perhaps 
minute  thrombi  be  formed  in  the  cerebral  cortex. 

It  is  certainly  exceptional  for  the  symptoms  of  confusional  insanity  to 
follow  immediately  or  even  rapidly  upon  the  aniBsthesia.  The  disease  is 
not  a  very  rare  one,  and  I  have  myself  seen  a  large  nunilier  of  cases.  In 
no  one  instance  has  any  relation  between  the  ansesthesia  and  the  mental 
symptoms  been  traceable ;  always  some  days,  and  usually  several  weeks, 
have  elapsed  after  the  operation  before  the  coming  on  of  the  mental 
symjitoms.  Under  such  circumstances  the  disturbance  of  mentality  can 
hardly  be  attributed  to  the  narcosis.  Rather  is  it  the  outcome  of  a  j)ecu- 
liar  depression  of  the  cerebral  cortex  produced  ]>robably  by  the  coinci- 
dent action  of  the  shock  of  the  operation  itself,  of  the  emotional  strain, 
and  of  the  various  depressing  factors  inseparal)le  from  a  surgical  illness. 

Disturbances  of  Renal  Secretion. — The  subject  of  the  action 
of  anaesthetics  upon  the  kidney  structure  has  already  been,  I  think,  suf- 
ficiently discussed  in  connection  with  the  cpiestion  as  to  the  influence  of 
disease  upon  the  choice  of  an  aniesthetic. 

Many  years  ago  a  well-known  Philadelphia  surgeon  attributed  the 
diabetes  which  occurred,  and  finally  proved  fatal,  in  his  own  person  to 
the  inhalation  of  nitrous  oxide,  and  in  1886  the  French  writer.  Dr. 
Lafont,-  affirmed  that  he  had  seen  abortion  with  death  of  the  foetus 
occur  at  the  moment  of  anaesthesia  from  nitrous  oxide,  and  that  he  had 
noticed  chlorosis,  albuminuria,  and  especially  true  diabetes,  follow  the 
inhalation  of  the  gas.  He  especially  warns  against  the  possible  ]>roduc- 
tion  of  diabetes  mellitus,  reporting  a  case  in  which  sugar  appeared  in  the 
urine  twice  after  use  of  the  gas ;  and  also  stating  that  he  had  been 
enabled  to  produce  glycosuria  in  the  dog  and  also  in  his  own  person  by 
the  inhalation.  The  high  blood-pressure  which  occurs  during  the  nitrous- 
oxide  narcosis  is  without  doubt  attended  with  venous  stasis,  and  it  does 
not  seem,  a  priori,  impossible  to  have  as  an  after-effect  of  such  narcosis 
various  symptoms  produced  by  change  in  the  cerebral  centres. 

On  the  other  hand,  nitrous-oxide  anesthesia  has  been  produced  so 
many  millions  of  times  that,  if  it  were  really  often  the  cause  of  serious 
after-effects,  it  seems  hardly  possible  but  that  overwhelming  evidence 
would  be  at  this  time  forthcoming  ;  and  careful  inquiry  made  by  myself 
of  persons  whose  sole  business  has  been  for  years  the  administration  of 
nitrous  oxide  for  the  extraction  of  teeth  shows  that  in  no  instance  have 
patients  returned  to  them  with  complaints.     Moreover,  in  experiments 

*  Brit.  Med.  Joiini.,  1887.  ^  La  France  mkl,  vol.  i.,  1886. 


AFTER-EFFECTS  OF  ANESTHESIA.  665 

upon  five  dogs  made  by  Drs.  Geo.  S.  Woodward  and  Alfred  Hand  in 
the  pharmaciilogioal  laboratory  of  the  University  of  Pennsylvania 
nt'itiu'r  albmninuria  nor  glycosuria  was  produced  by  the  repeated  and 
prolonged  iniiahition  of  nitrous  oxide.  At  ])rcscnt,  therefore,  it  would 
.seem  that  when  the  patient  is  a  normal  individual  the  surgeon  should 
have  no  fear  of  any  after-eifects  from  nitrous  oxide. 

Disturbances  of  the  Liver. — Frericiis  states  that  jaundice  some- 
times follows  the  inhalation  of  chloroform  and  ether,  but  such  cases  must 
be  of  exceeding  rarity.  I  have  myself  never  met  with  tliem  in  litera- 
ture, and  Murchison  states  that  after  careful  examination  he  has  never 
been  able  to  find  a  record  of  a  case.  On  the  otiier  hand,  Bernstein,'  and 
also  Levden,^  have  found  traces  of  bile-|)igment  in  the  human  urine  after 
chloroform  narcosis ;  and  Nothnagel '  has  recognized  biliary  coloring 
matters  in  the  urine  of  rabbits  after  subcutaneous  injection  of  chloroform 
or  ether;  but  Kappeler^  in  twenty-five  cases  of  chloroform  narcosis  was 
not  al)le  to  obtain  a  trace  of  biliary  coloring  matter  ;  further,  ciiloroforra 
mixed  with  blood  outside  of  tiie  body  raj)idly  destroys  the  red  corpusi'les, 
liberating  iia?moglobin,  and  it  is  possible  tiiat  in  rare  cases  of  protracted 
chloroform  narcosis  some  such  action  occurs  within  the  body,  yielding 
icteric  products.  On  the  whole,  it  does  not  seem  probable  that  chloro- 
form lias  any  important  influence  upon  tiie  liver,  save  only  as  part  of  the 
wides})rcad  action  upon  the  tissues  next  to  be  spoken  of. 

The  General  Nutrition. — As  long  ago  as  1850,  Caspar  mentioned 
fthronic  poisoning  by  means  of  chloroform,  and  somewhat  later  Liman 
affirmed  that  after  2>rolonged  chloroformization  patients  sometimes  pass 
into  an  abnormal  condition  whicli  continues  for  days,  even  for  weeks,  and 
finally  ends  in  deatii,  tlie  whole  being  tiie  result  of  the  influence  of  the 
cidoroform.  These  views  met  with  little  acceptance,  and,  indeed,  seemed 
eonnnonly  to  have  been  overlooked  or  disregarded,  until  Dr.  E.  Ungar 
demonstrated  by  experiments  upon  the  lower  animals  that  prolonged 
chloroform  narcosis  has  a  profound  influence  upon  the  general  nutrition.^ 
He  found  that  in  the  dog,  when  narcosis  was  kept  up  for  many  hours 
and  repeated  once  or  twice  at  short  intervals,  tiiere  was  a  widespread 
fatty  degeneration,  usually  of  a  very  liigh  grade,  in  tlie  heart-muscle 
and  in  tlie  liver  and  kidneys,  but  more  or  less  pronounced  in  the  spleen, 
in  the  general  epithelial  tissues,  in  the  voluntary  nuiscles,  and,  in  fact, 
in  all  of  the  higher  tissues.  That  this  change  was  not  secondary  to  any 
alteration  in  tlie  blood  by  the  chloroform  is  believed  by  Ungar  to  be 
shown  by  the  fact  that  no  change  could  be  noted  in  the  red  blood-cor- 
puscles, nor  were  bile  acids  to  l)e  found  in  the  urine,  nor  was  there  ever 
any  h;emoglobinuria. 

These  researches  have  been  confirmed  in  their  general  results  in 
numerous  exjieriments  npon  animals  by  Strassmami,^  by  Ostertag,''  and 
bv  Kast  and  Mcster.**'  Further,  in  a  series  of  very  careful  studies  upon 
four  human  subjects  dying  after  prolonged  chloroformization  Dr.  Eugene 
FraenkeP  has  fi)und  a  widespread  necrotic  degeneration,  associated  with 

'  Muleschatf.1  Uidersuchungen,  1870. 

''  lii'itnige  zur  Pathnhgie  Sea  Icterus,  Berliu,  ISGO. 

'  liidin.  klin.  Wochetisch.,  1866.  *  Die  Ana'slhetlca,  Stuttgart,  1880. 

'  Vicrktjuhresb.  f.  Geriehlliche  med.,  N.  F.,  46-47,  1887. 

8  Virchow's  Archie,  Bd.  11-^.  '  Pml.,  Bd.  118. 

^  Zcitichr.  klin.  Med.,  xviii.,  1891.  '  Virchow's  Archie,  Bd.  127  aud  129. 


6^6  AN^HSTIIESIA. 

■A  deposition  of  much  pigment  in  many  places  and  in  all  portions  of  the 
Ixidy,  but  especially  affecting  the  heart-muscle  and  the  epithelium  of  the 
kidney. 

In  further  conlirmation  of  the  powerful  iuthience  of  cliloroform  on 
nutrition  there  are  the  observations  of  Salkowsivi,  that  marked  increase 
in  the  output  of  nitrogenous  waste  is  caused  by  the  administration  of  the 
drug  to  dogs;  of  Kust  and  Mester,  that  there  is  a  marked  increase  in 
the  elimination  of  chlorine  and  nitrogen  produced  by  the  auiustlictic  ; 
and  of  Petruschky,  that  after  death  from  ehlorcjform  the  intercellular 
juices  become  rapidly  acid.  Ostertag  in  his  conclusions  differs  some- 
what from  Ungar  in  believing  that  the  fatty  degeneration  is  in  part  due 
to  the  destruction  of  the  red  blood-corpuscles  by  the  chloroform.  As, 
however,  he  also  believes  that  the  destruction  of  the  protoj)lasm  is  in 
part  effected  by  the  direct  influence  of  the  chloroform,  the  difference 
between  his  views  and  those  of  Ungar  is  not  vital.  Moreover,  whatever 
of  scientific  interest  may  attach  to  the  method  in  which  chloroform  pro- 
duces its  ravages,  to  the  surgeon  the  method  is  of  little  practical  import- 
ance, the  vital  fact  l)eing  that  chloroform  itself,  directly  or  indirectly, 
destroys  the  living  protoplasm  in  almost  all  portions  of  the  human  body. 
It  seems  to  me,  therefore,  that  it  nuist  be  considered  an  estiiblished  fact 
that  a  prolonged  inhalation  of  chloroform  directly  affects  the  general 
nutrition  of  the  vital  organs,  and  is  capable  in  this  way  of  causing  organic 
changes  which  may  produce  death  very  soon  after  the  inhalation,  or  may 
take  days  or  even  weeks  to  work  out  the  fatal  result. 

Certainly,  enough  has  been  made  out  in  regard  to  the  action  of  chlo- 
roform upon  the  nutrition  to  condenui  the  present  total  disregard  by 
practical  surgeons  ( if  this  influence.  When  the  amiesthesia  is  of  short  dura- 
tion the  influence  of  the  chloroform  uj)on  nutrition  is  probably  of  little  or 
no  importance,  but  in  those  operations  which  require  one  or  several  hours 
for  their  performance  the  matter  seems  very  serious.  In  such  a  case  it 
is  essential  to  sele(.'t  that  ansesthetic  which  has  the  least  influence  upon 
nutrition.  Unfortunately,  though  we  know  so  much  in  regard  to  chloro- 
form, we  have  no  positive  knowledge  in  regard  to  ether.  Undoubtedly, 
it  shares  the  power  of  chloroform  of  destroying  the  red  blood-corpuscles 
and  setting  free  the  oxyhemoglobin  in  freshly-drawn  blood,  but  beyond 
this  we  have  no  evidence.  A-priori  reasoning,  however,  leads  to  the  be- 
lief that  ether  probably  disturbs  nutrition  much  less  than  does  chloroform. 
The  researches  of  A.  Zeller'  indicate  that  chloroform  is  in  part  at  least 
decomposed  in  the  system.  Chlorine  is  chemically  very  closely  allied  to 
iodine ;  the  deleterious  influences  upon  protoplasm  of  the  iodine  com- 
j)ounds  set  free  by  the  decomposition  of  iodoform  are  well  known  ;  prob- 
ably the  chlorine  compounds  set  free  by  the  decomposition  of  chloroform 
act  similarly.  There  is  also  much  reason  for  tlie  belief  that  bromide 
of  ethvl  is  lial)le  to  be  decomposed  in  the  system  and  to  yield  bromme 
compounds  capable  of  seriously  att'ecting  nutrition. 

Ether  is  not  eliminated  to  any  ajipreciable  extent  by  the  kidneys :  in 
the  experiments  of  Dr.  Geo.  B.  ^\'ood  it  was  found  that  whilst  one  drop 
of  ether  could  be  detected  in  two  ounces  of  urine  by  the  process  used,  no 
ether  whatever  could  be  found  in  numerous  trials  in  the  urine  drawn  at 
the  time  and  at  varying  intervals  after  prolonged  surgical  etherization. 

^  Ze'U^chr.  f.  pJuji^ioloij.  ChcmitJ,  Bd.  viii. 


ADMINISTRATION.  6G7 

Tliere  is,  of  course,  much  escape  of  etlier  from  tlic  body  through  the 
hing-s,  hut  plainly  it,  like  alcoiiol,  is  larirely  destroyed  in  the  organism. 
In  its  destruction  it  must  yield  the  same  products  as  does  alcoiiol,  and, 
since  no  deleterious  compound  can  be  educed  from  it,  it  seems  highly 
improbable  that  it  should  affect  nutrition  as  does  chloi'oform.  On  the 
otiier  hand,  it  is  probable  that  the  long-continued  use  of  alcohol  will 
cause  fatty  degeneration,  and  the  matter  is  so  important  that  it  should 
be  at  once  put  to  the  test  of  experiment. 

In  reviewing  the  whole  subject  it  seems  to  me  that,  although  our 
knowledge  is  imperfect,  the  surgeon  who  desires  to  produce  a  prolonged 
narcosis  should  prefer  ether  to  chloroform,  unless  there  be  in  the  peculiar- 
ities of  the  individual  case  positive  reasons  to  the  contrary. 

Administration. 

"V^lieuever  it  is  possible  the  patient  should  be  prepared  for  the  use  of 
an  anesthetic  by  an  abstinence  from  food  for  at  least  four  hours,  and 
usually  any  food  given  inside  of  six  hours  should  be  very  light  and 
thoroughly  digestible,  so  that  the  ana^sthetizer  can  be  sure  of  the  em])ti- 
ness  of  the  stomach.  Whenever  circumstances  render  such  preparation 
im])ossible,  and  the  ansesthetic  has  to  be  given  although  the  stomach  is 
full,  the  greatest  care  should  be  exercised  to  prevent  any  of  the  contents 
of  the  stomach  from  entering  the  trachea.  It  should  be  remembered  that 
vomiting  may  occur  not  only  after  the  antesthesia,  but  at  any  time  dur- 
ing its  course,  in  which  case  the  patient  should  be  placed  with  the  head 
upon  one  side  or  ])artially  downward  to  facilitate  the  possibility  of 
discharge  through  the  mouth,     (yoe  ]).  060.) 

It  is  a  common  belief,  at  least  in  some  ])ortions  of  America,  that  the 
administration  of  an  ounce  of  whiskey  or  brandy  before  the  use  of  the 
anaesthetic  lessens  the  chances  of  severe  nausea  or  vomiting.  The  cor- 
rectness of  this  belief  is  not  certain,  although  I  deem  the  procedure  a 
good  one. 

In  cases  in  which  there  is  any  especial  reason  to  fear  the  action  of 
the  anaesthetic  upon  the  heart,  a  hypodermic  injection  of  the  tincture  of 
digitalis  may  be  administered  from  half  an  hour  to  an  hour  before  the 
an;¥sthesia.  Ten  to  fifteen  minims  thrown  into  the  subcutaneous  tissues 
with  proper  antiseptic  precaution  will  rarely  jn-oduce  any  local  disturb- 
ance bevond  some  burning  or  smarting.  In  cases  of  very  weak  heart  it 
would  probablv  he  wiser  to  begin  to  produce  the  influence  of  the  digitalis 
twelve  to  twenty-four  hours  before  the  administration  of  ether.  Even 
in  ordinary  cardiac  cases  the  hypodermic  use  of  strychnine  before  the 
inhalation  may  be  of  great  service  ;  and  when  there  is  a  general  tendency 
toward  collapse  or  shock  atropine  or  strychnine  should  always  be  admin- 
istered to  ])revent,  if  possible  accident.  The  action  of  the  various 
anavtlKtics  is  so  different  tiiat  different  methods  of  administration  are 
required. 

Ktheriz<dion. — The  instruments  and  mctiiods  which  have  been  brought 
forward  from  time  to  time  for  the  giving  of  ether  by  inhalation  are 
legion,  but  all  plans  now  in  use  may  be  arranged  under  two  headings  : 
first,  open  administration — methods  in  which  free  access  of  air  is 
allowed ;  second,  closed  administration — methods  in  which  the  patient 


668  ANESTHESIA. 

broatlies  out  of  and  into  a  bag  with  more  or  less  imperfect  supply 
of  air. 

It  is  evident  that  when  a  patient  breathes  in  and  out  of  a  receptacle 
containinir  ether,  in  addition  to  etlierization  there  is  more  or  less  complete 
asphyxiation,  tiie  degree  of  tlie  aspiiyxia  of  course  l)eing  dependent  upon 
the  size  of  the  original  reservoir  of  air  and  the  amount  of  fresii  air  allowed 
to  enter  the  reservoir  tluring  the  inlialati(jn. 

Some  years  ago,  at  the  clinic  of  the  hospital  of  the  University  of 
Pennsylvania,  etherization  was  produced  by  simply  setting  a  large 
bottle  freshly  tilled  with  other  in  hot  water,  and  C(jnnecting  this  with 
a  face-mask  which  was  so  ])laced  over  the  mouth  and  nose  of  the  patient 
that  the  breathing  was  simply  in  and  out  of  the  bottle.  The  result  of 
this  simple  apparatus  was  at  first  all  that  could  be  desired  :  anaesthesia 
was  usually  complete  in  two  or  three  minutes,  was  well  and  thoroughly 
maintained,  but  the  jiractice  had  not  long  been  kept  uj)  when  serious 
asphyxial  accidents  began  to  occur,  and  became  so  frequent  and  so 
severe  as  rapidly  to  lead  to  the  abamlonment  of  the  method.  There 
can  be  no  doubt  but  that  just  in  ])roportion  as  the  jiatient  is  not 
allowed  to  breathe  fresh  air  is  the  rapidity  of  the  etherization  hastened ; 
but  it  seems  to  me  apparent  that  in  proportion  as  the  rapidity  of  the 
coming  on  of  anasthcsia  is  hastened,  so  is  the  danger  of  asphyxia 
increased. 

I  am  not  able  to  give  positive  statistics,  but  the  number  of  deaths 
reported  in  the  last  eight  years  in  England  from  ether  is,  I  believe, 
much  greater  than  those  which  have  been  reported  as  occurring  in  the 
United  States,  although  ether  is  much  more  largely  used  in  the  latter 
than  in  the  former  country.  The  closed  method  of  administration  is 
very  rarely  employed  in  America,  and  it  seems  a  natural  conclusion 
that  the  closed  method  of  administration  is  more  dangerous  than  the 
open — a  conclusion  which  is  greatly  strengthened  by  the  fact  tiiat  Dr. 
Hewitt,  who  practises  the  closed  method,  is  continually  cautioning  his 
readers  to  see  that  the  air-valves  are  opened,  so  that  a  free  admission  of 
air  is  allowed  -whenever  previous  disease  adds  more  than  the  wonted 
danger  to  the  use  of  ether.  In  recommending  Ormsby's  inhaler  as 
superior  to  Clover's  for  maintaining  etherization  Professor  Hewitt 
says  :  "  I  have  often  known  cyanosis  quickly  to  vanish  and  the  lireath- 
ing  to  become  less  hampered  by  effecting  this  change  of  inhalers  during 
deep  ether  ansesthesia."  I  believe  any  closed  inhaler  hampers  the 
breathing  and  increases  the  cyanosis  of  etlierization.  There  ought  not 
to  be  any  cyanosis  in  etherization.  My  own  experience  with  closed 
inhalers  has  not  been  large — indeed,  solely  with  Clover's  apparatus — but 
whenever  I  have  seen  closed  ether  ajiparatus  used  the  evidences  of 
asphyxia  and  early  disturbances  of  respiration  have  certainly  been  much 
more  frequent  than  I  have  been  accustomed  to  witness  with  the  open  inha- 
lation. The  saving  of  ether  effected  by  the  closed  method  is  of  no  import- 
ance Avhatever ;  the  saving  of  time  is  very  slight.  In  a  series  of  obser- 
vations which  were  made  for  me  at  the  surgical  clinic  of  the  Jefferson 
Medical  Hospital  of  Philadelphia  the  average  time  required  for  the 
])roduction  of  complete  unconsciousness  by  the  open  method  was  eight 
minutes ;  and  in  a  similar  series  of  observations  made  in  the  surgical 
•clinic  of  the  hospital  of  the  University  of  Pennsylvania  the  average 


ADMINISTRATION.  669 

time  required  for  complete  etlicrizatiou  by  the  Allis  inhaler  was  seven 
and  nine-tenths  minutes.  The  results  of  these  two  series  are  so  close 
that  eight  minutes  must  be  considered  as  the  average  time  required  for 
full  open  etherization ;  with  closed  etherization  this  period  can  scarcely 
be  shortened  to  less  than  fonr  or  five  miiuites. 

Open  Etherization. — Open  etherization  is  often  practised  by  simply 
folding  a  towel  into  the  form  of  a  cone,  pinning  the  edges  with  safetv- 
pins,  and  ])utting  the  ether  inside.  This  is  a  rough  and  disagreeable 
plan — a  jilan  which  involves  the  greatest  amount  of  suffering  to  the 
patient  and  the  least  amount  of  satisfaction  to  the  surgeon.  In  many 
cases  the  towel  is  so  used  as  mechanieally  to  interfere  with  respiration. 
The  inhaler  invented  by  Dr.  O.  H.  Allis  is  based  upon  the  theorv  that 
the  patient  to  be  etherized  should  be  supplied  with  an  abundance  of  air 
saturated  with  the  vajxir  of  etlier.  It  consists  essentially  of  a  series  of 
foldings  of  muslin  on  a  wire  framework,  arranged  almost  like  the  gills 
of  a  fish,  so  as  to  allow  the  air  to  pass  freely  through,  but  everywhere 
to  come  in  contact  with  ether.  It  should  be  placed  upon  the  face  of  the 
patient  dry,  and  the  ether  gradually  pf)ured  from  a  bottle  whose  cork 
has  two  small  tubes  so  placed  in  it  that  when  the  bottle  is  tilted  ether 
runs  out  of  one  tube  and  air  enters  through  the  other.  Such  a  bottle  is 
known  in  Philadelphia  as  the  "  polyclinic  liottle."  When  ])ropcrlv  used 
the  Allis  inhaler  largely  does  away  with  the  sense  of  suflbcation,  and  the 
consequent  struggles  which  have  made  etherization  so  repidsive  alike  to 
patient  and  surgeon. 

Vto.'ied  Etherization. — In  England  the  Clover  and  Ormsby  inhalers  are 
very  commonly  used.  Of  these  inhalers,  Ormsby's  appears  to  me  to  be 
simpler  and  the  less  dangerous,  because  of  its  being  more  open.  The 
following  general  rules  are  copied  from  the  recent  book  (1893)  of  Pro- 
fessor F.  W.  Hewitt,  to  which  the  reader  is  referred  for  further  details. 
No  one  imaccustomed  to  the  use  of  these  inhalers  should,  in  mv  opinion, 
attempt  their  eni])loynient  without  having  carefully  studied  pages  145 
to  150  of  the  work  just  alluded  to. 

Clover  Inhaler. — 1.  Pour  out  any  ether  that  may  have  been  left 
from  a  previous  administration. 

2.  In  cold  weather  partially  immerse  the  ether  reservoir  in  warm 
water  for  a  few  minutes  before  use. 

3.  Pour  in  through  the  filling  tube  one  and  a  half  ounces  of  ether, 
rc])lace  the  stopper  or  cork,  and  turn  the  indicator  to  "  0." 

4.  Fit  on  a  face-piece  of  ajipropriate  size,  and  blow  out  through  the 
apparatus,  in  order  to  expel  all  traces  of  ether  vapor  that  might  possibly 
be  present  in  the  shaft  of  the  aj)paratus. 

5.  Gently  but  accurately  adapt  the  face-piece  to  the  face  of  the 
patient,  and  request- him  to  breathe  in  and  out  quite  freely. 

6.  When  the  patient  is  breathing  freely  attach  the  bag  to  the  ether 
reservoir. 

7.  Allow  the  jiatient  to  breathe  backward  and  forward  for  about 
half  a  minute  before  turning  on  any  ether  vapor. 

8.  Having  allowed  the  patient  to  breathe  his  own  expirations  back- 
ward and  forward  for  the  time  mentioned,  very  gradually  rotate  the 
ether  reservoir,  so  that  the  "  0 "  on  its  circumference  moves  almost 
imperceptibly  but  yet  continuously  away  from  the  indicator. 


670  ANESTHESIA. 

9.  Fresh  air  should  not  he  given  till  there  is  a  distinct  indication 
for  it. 

10.  AVlien  a  breath  of  fresh  air  is  j^iven  the  strengtli  of  vajxjr  should 
be  increased,  otiierwise  the  j)atient  may  come  out  of  the  auiesthcsia. 

11.  Should  symptoms  of  excitement  arise  and  struggling  commence, 
the  inhaler  should  be  kept  closely  applied. 

12.  When  the  breathing  has  become  r(>gular  and  stertorous  and  the 
conjunctiva  insensitive  (these  signs  usually  manifest  themselves  in  about 
two  and  a  half  or  three  minutes)  the  inhaler  should  be  removed  for 
two  or  three  In'caths. 

13.  In  ordinary  cases  it  is  unnecessary,  in  order  to  secure  full 
anaesthesia,  to  rotate  the  ether  reservoir  beyond  "  3." 

14.  When  once  full  surgical  anaesthesia  has  become  established  the 
anresthetist  will  be  able  to  turn  back  the  ether  reservoir  to  "  2,"  1^,"  or 
even  "  1,"  and  to  admit  air  in  sufficient  quantities  to  avoid  cyanosis. 

15.  Be  careful  to  replenish  the  ether  reservoir  before  the  ether  in  it 
is  exhausted. 

Oniifibi/  Inhaler. — 1.  Wring  out  the  sponge  in  warm  water,  and, 
having  squeezed  it  as  dry  as  possible,  place  it  in  the  cage. 

2.  Pour  upon  the  sponge  about  half  an  ounce  of  ether. 

3.  Very  gradually  bring  the  inhaler  toward  the  face  of  the  patient, 
and  if  an  air-slot  be  used  see  that  it  is  open. 

4.  Encourage  the  patient  to  breathe  as  freely  as  j)0ssible,  and  grad- 
ually close  the  air-slot. 

5.  Be  prepared  for  the  patient  attempting  to  push  away  the  inhaler, 
rising  from  the  bed,  etc. 

6.  Should  the  sponge  freeze,  another  one,  wrung  out  as  before,  should 
be  substituted  and  fresh  ether  added. 

7.  When  more  ether  is  needed  about  half  an  ounce  at  a  time  should 
be  added  to  the  sponge. 

Except  inider  the  most  peculiar  circumstances  the  ansesthetic  should 
always  be  administered  by  a  skilletl  attendant  rather  than  by  the  operating 
surgeon.  This  rule  rests  upon  two  foundations  :  In  the  first  place,  occa- 
sionally during  the  stage  of  antesthetic  excitement  there  is  sexual  stim- 
ulation which  may  go  on  to  a  complete  orgasm  and  lead  to  after-compli- 
cations if  the  operator  and  patient  be  of  opposite  sexes.  In  the  second 
place,  the  person  who  gives  the  antesthetic  must  pay  the  strictest  atten- 
tion during  the  whole  period  to  the  condition  of  the  patient,  as  the  life 
of  the  latter  may  dejiend  upon  the  recognition  of  the  early  symptoms 
of  accident.  The  celebrated  Hyderabad  C'ommission,  in  the  most  urgent 
and  forcible  terms,  has  drawn  attention  to  the  respiratory  function 
as  affording  the  chief  seat  of  danger,  and  has  asserted  that  failure  of 
respiration  always  precedes,  and  is  really  the  cause  of,  collapse  of  the 
circulation.  There  is  no  room  for  dispute  as  to  the  importance  of  a 
gradually  produced  asphyxia  in  the  weakening  of  the  heart,  but  cardiac 
depression  and  fiilure  of  circulation  are  just  as  important  as  is  failure  of 
the  respiration,  so  that  the  ana\sthetizer  who  neglects  the  pulse  is  most 
culpable.     Both  respiration  and  circulation  must  be  relentlessly  watched. 

Failure  of  the  circulation  occurring  at  any  time  during  ansesthesia  is 
of  most  serious  import,  but  the  meaning  of  respiratory  failure  depends 
ujjon  when  it  occurs.     Especially   is  this  true  if  ether  be  employed. 


ADMINISTRATION.  G71 

Early  in  etherization  the  irritating  influence  of  the  va})or  upon  the 
mucous  membrane  and  the  ftiuces  of  the  upper  respiratory  tract  fre- 
quently produces  reflex  disturbances  or  even  arrest  of  the  respiratory 
movements.  Such  an  occurrence  should,  however,  be  the  signal  for 
giving  the  anfestiietic  more  freely,  since  tlie  respii-atory  disturbance  is 
not  accompanied  with  any  danger,  and  is  at  once  suspendeil  ^\hcn  suf- 
ficient of  the  anaesthetic  has  been  taken  to  obtund  the  nerve-centres. 
On  the  otlier  hand,  any  irregularities  of  respiration  occurring  after 
aniesthesia  has  been  thoroughly  induced  imjieratively  demand  the  imme- 
diate withdrawal  of  the  anesthetic.  In  1874,  Dr.  Baudin  called  atten- 
tion to  tiie  jiupil  as  a  guide  in  chloroformization,  stating  tliat  it  is  at  first 
uniformly  dilated,  Init  afterward  is  uniformly  and  immovably  contracted, 
and  tiiat  the  jieriod  of  contraction  is  the  period  for  operation.  Since  tlie 
publication  of  Baudin's  memoir  the  matter  has  been  much  discussed 
both  by  physiologists  and  clinicians.  As  a  general  rule,  during  deep 
chloroform  auresthesia  there  is  decided  but  not  minute  contraction  of  tlie 
pupil,  and  if  during  tlie  antesthesia  the  jnipil  returns  to  norm,  more 
chloroform  is  required,  but  if  it  suddenly  dilate,  danger  is  imminent. 
It  has  been  shown,  however,  by  the  experiments  of  Holmgren,  Kratsch- 
mer,  and  others  that  this  general  rule  is  often  departed  from — that  in  the 
lower  animals  the  pupils  vary  greatly  during  chloroformization ;  and 
there  can  be  no  doubt  that  this  is  also  true  in  regard  to  man.  Sometimes 
the  pupil  dilates  early  in  the  chloroformization,  and  remains  dilated 
througii  the  comj^lete  anaesthesia  ;  again,  nor  rarely,  especially  wiien  the 
operation  occurs  in  the  region  of  the  neck,  the  ])upil  alternately  dilates 
and  contracts  during  a  chloroformization. 

During  etherization  the  common  rule  is  for  tlie  pupils  to  be  of  mode- 
rate size  or  even  slightly  dilated,  whilst  in  very  deep  ether  anesthesia 
there  is  often,  perhaps  commonly,  pronounced  dilatation.  On  tiie  otiier 
hand,  in  a  considerable  projwrtion  of  cases  the  ]>u])ils  contract  during 
etiierization,  whilst  in  other  cases  the  size  of  the  pupil  varies  very  much, 
and  often  inadvertently,  during  one  etherization.  It  is  evident  that  the 
pupils  cannot  be  relied  upon  as  a  guide  during  the  administration  of  an 
anesthetic,  though  some  inference  may  be  derived  from  their  study. 

Much  more  important  to  the  anestiietizer  are  the  color  and  expression 
of  the  tace.  The  face  should  be  carefully  watched  ;  any  cyanotic  apjiear- 
ance  denotes  ajiproaching  asphyxia,  whilst  an  excessive  pallor  is  indica- 
tive of  failing  circulation.  Severe  ansesthetic  accidents  are  often,  if  not 
usually,  immediately  preceded  by  a  sudden  change  sweeping  over  the 
expression  of  the  face  like  the  alteration  of  the  summer  landscape  by  a 
flying  cloud.  This  danger-signal  is  so  imjwrtant,  so  freciuent,  and  so 
imperative  that  the  anesthetizer  should  always  carefully  watch  the 
countenance  of  the  patient. 

The  importance  of  a  careful  watch  over  the  jiulse  is  so  obvious  as 
not  to  need  any  detailed  discussion  here,  and  I  only  call  attention  to  the 
convenience  of  the  temporal  artery  for  the  purposes  of  the  aniesthetizcr. 

Any  danger-signal  occurring  during  the  administration  of  an  anes- 
thetic should  lead  to  the  immediate  withdrawal  of  the  inhaler  and  the 
attempt  at  resuscitation  of  the  patient.  The  measures  employed  fiir  the 
latter  puiiiose  of  course  vary  according  to  the  direction  from  which  the 
danger  comes.     Usually  the  first  procedure  is  to  see  that  there  is  no 


672  ANJESTHESIA. 

ohstriic'tioii  to  the  respiratory  passages  by  the  tlirowiiig  back  of  the 
paralyzed  parts  upon  the  larynx.  Various  methods  have  been  advo- 
cated. Formerly  all  that  ^vas  considered  necessary  was  simj)ly  to  draw 
forward  the  tongue,  but  Dr.  Benjamin  Howard  showed  that  this  does  not 
necessarily  accomplish  the  ]nirpose,  and  proposed  the  extension  of  the 
head  and  neck.  In  an  elaboi-ate  series  of  experiments,  however,  made 
in  the  lal)oratory  of  the  University  of  Pennsylvania,  Drs.  Hobart  A. 
Hare  and  Edward  Martin  proved  that  the  method  of  Howard  is  often 
inefficient,  and  that  the  best  results  are  to  be  obtained  by  carrying  out 
the  following  rule  :  "  Place  the  index  finger  of  each  hand  upon  the  cor- 
responding cornua  of  the  hyoid  bone,  whilst  the  middle  fingers  rest  upon 
the  angle  of  the  jaw,  and  then  ])ress  forward  and  upward,  the  same  force 
serving  to  extend  the  head  uj>on  the  neck  ;  if  this  fails  to  open  the  glottis, 
by  means  of  a  tenaculum  thrust  far  back  into  the  base  of  the  t»ngue 
draw  it  forward." 

Whilst  the  manipulation  spoken  of  is  going  on  an  assistant  should 
strip  the  chest  of  the  patient,  and  by  slapping  it  with  a  cold  wet  towel 
or  by  pouring  a  little  ctlier  over  it,  so  as  to  get  the  effect  of  cold,  should 
endeavor  to  stimulate  respiration.  If  there  be  failure  of  the  pulse,  no 
time  is  to  be  lost ;  inversion  of  the  body  is  to  be  practised  immediately. 
This  method  of  treating  anaesthetic  cardiac  fiiilure  has  been  commonly 
claimed,  especially  in  Europe,  as  having  originated  with  the  Parisian 
surgeon,  Nelaton,  but  the  profession  is  really  indebted  for  it  to  an  Amer- 
ican, Dr.  E.  L.  Holmes  t)f  Chicago,  who  as  long  ago  as  1868,  speaking 
of  anaesthetic  accidents,  said  :  "  WJienever  there  is  any  failure  of  the 
heart's  action,  as  is  nearly  always  the  case,  the  body  should  be  laid  at 
an  angle  of  forty  degrees,  with  the  head  downward,  so  as  to  favor  the 
passage  of  arterialized  blood  to  the  brain." 

Inversion  of  the  body  does  not,  however,  act  as  a  resuscitant  in  the 
manner  which  was  believed  by  Dr.  Holmes  and  universally  accepted  by 
the  profession.  The  series  of  experiments  which  I  made  for  the  address 
delivered  before  the  Berlin  Congress  of  1890  demonstrated  that  in  the 
body  of  the  animal  whose  circulation  has  been  paralyzed  by  chloroform 
the  whole  arterial  and  venous  system  acts  in  a  measure  like  a  single  tube 
filled  with  fluid.  Thus,  if  the  feet  of  the  dog  were  raised  \ertically 
above  the  head  M'hilst  the  latter  remainetl  n])on  the  table,  an  immediate 
rise  of  pressure  always  occurred  in  the  carotid  artery,  even  if  the  heart 
had  practically  ceased  beating,  ]irovided  that  the  head  of  the  animal  ^^'as 
kept  upon  a  level  with  the  table — that  is,  upon  a  level  with  the  mano- 
metrical  tube.  If,  h(jwever,  the  head  of  the  animal  was  de])ressed  below 
the  level  of  the  table  for  a  distance  ecpial  to,  or  greater  than,  the  length 
of  the  body  of  the  animal,  a  decrease  of  the  arterial  pressure  occurred  at 
once,  although  the  animal  was  in  a  vertical  position.  The  phenomena 
observed  were  precisely  such  as  would  have  been  produced  if  the  canula 
had  been  inserted  into  a  tube  filled  with  fluid,  instead  of  into  the  carotid 
artery,  and  the  elevation  and  depression  of  this  tube  had  registered  itself 
on  the  recording  drum  in  obedience  to  the  ordinary  laws  of  hydrostatics. 
The  phenomena  were  entirely  independent  of  any  beat  of  the  heart,  and 
could  usually  be  produced  when  the  animal  was  dead,  provided  the 
death  had  not  occuri-ed  too  long  previously.  Sometimes,  even  a  very 
few  minutes  after  the  cessation  of  the  heart-beat,  it  was  impossible  to 


ADMINISTRATION.  673 

bring  about  the  changes  of  pressure,  pmhably  because  coagulation  of 
tlic  blood  had  occurred  to  an  extent  sufficient  to  interfere  with  the  liquid 
properties  of  the  fluid.  In  no  case  was  any  etfect  upon  the  respiration 
caused  by  change  in  the  position  of  the  animal.  In  a  number  of  cases, 
however,  when  the  feet  were  elevated  the  heart,  which  had  entirely  ceased 
beating,  recommenced  its  work,  and  I  have  several  times  seen  a  j^ulse 
entirely  disappear  when  the  animal  \vas  taken  from  the  vertical  to  the 
horizontal  position.  On  the  other  luind,  very  frequently  it  was  impos- 
sible to  afieot  the  cardiac  action  by  changing  the  position  of  the  animal. 
N(>vertheless,  the  restoratiou  of  cardiac  movements  occurred  too  fre- 
quently to  be  a  mere  outcome  of  chance,  though  I  several  times  noted  that 
tiie  heart  was  more  affected  by  alternately  elevating  and  depressing  the 
feet  of  the  animal  than  by  keeping  it  in  a  steadily  elevated  or  horizontal 
position.  The  action  of  inversion  in  the  ana?sthetic  accident  is  therefore 
not  upon  the  respiratory  centre,  but  upon  the  heart.  When  the  circu- 
lation has  practically  ceased  in  anesthesia,  inverting  the  body  must  cause 
the  blood  which  has  collected  in  the  extremely  relaxed  vessels  of  the 
abdomen  to  flow  into  the  right  side  of  the  heart  and  distend  it ;  and  this 
distention,  tliis  increase  of  intra-cardiac  pressure,  may  at  a  critical  mo- 
ment have  an  influence  upon  the  failing  organ  sufficient  to  recall  it  into 
functional  activity. 

The  question  of  the  use  of  drugs  in  tiiese  accidents  is,  of  course,  an 
extremely  important  one.  The  more  important  remedies  which  previous 
to  1890  were  used  by  clinicians  for  the  averting  of  threatened  death 
were  ether,  alcohol,  ammonia,  amyl  nitrite,  digitalis,  atropine,  and  caf- 
feine. Although,  at  least  in  America,  hypodermic  injections  of  ether 
have  been  frequently  employed,  even  in  ether  accidents,  such  tise  is  so 
absolutely  absurd  that  it  does  not  seem  to  me  to  require  any  exper- 
imental evidence  of  its  futility.  Ether  in  the  blood  acts  as  ether, 
whether  it  finds  entrance  through  the  lungs,  through  the  rectum,  or 
through  the  cellular  tissue  ;  and  the  man  who  would  inject  ether  hypo- 
dermically  into  a  patient  who  is  dying  from  ether  should,  to  be  logical, 
also  saturate  a  sponge  \\ith  the  ether  and  crowd  it  upon  the  nose  and 
mouth  of  his  unfortunate  victim. 

Of  all  the  drugs,  that  which  was  primarily  most  relied  upon  by  the 
clinicians  as  a  cardiac  stimulant  in  auiesthesia  was  alcohol.  The  chemical 
and  physiological  relations  of  alcohol  to  ether  and  chloroform  are,  how- 
ever, so  close  that  many  years  ago  I  became  very  doubtful  of  the  value 
of  this  drug  as  a  stimidant  to  a  heart  dejiressed  by  ana?sthesia.  These 
doubts  continually  grew  stronger  from  what  I  saw  and  read  as  to  the 
effects  of  the  administration  of  alcohol  during  ana?sthesia,  and  were 
finally  changed  into  conviction  by  the  experiments  of  R.  Dubois,^  who 
found  that  in  the  animal  to  which  alcohol  has  been  freely  given  much 
less  cldoroform  is  required  than  in  the  normal  animal  to  anaesthetize  or 
to  kill;  or,  in  other  words,  that  alcohol  intensifies  the  influence  of  chloro- 
form and  lessens  the  fatal  dose. 

In  my  own  experiments,  made  for  the  a<l(lress  already  spoken  of,  from 
5  to  20  c.c.  of  an  80  per  cent,  alcohol,  well  diluted  with  water,  were  in- 
jected into  animals  in  which  the  heart  was  failing  during  advanced 
chloroform  anaesthesia.     In  no  case  was  I  able,  whether  the  amoiuit  was 

'  Progres  medical,  1SS3. 
Vol.  I.— 13 


674  AN^STJTESSTA. 

larov  or  small,  to  detect  the  sliffbtest  increase  in  the  piilse-M'ave  or  in  the 
arterial  pressure  produced  by  the  alcohol.  Wlieiiever  the  amount  of 
al(!oliol  was  sufficiently  large  to  produce  any  effect,  there  was  always  an 
increase  of  rapidity  in  the  fall  of  arterial  ])ressure  and  also  a  lessening  in 
the  size  of  the  jiulse- waves.  I  have  myself  no  douht  tiiat  in  not  a  few 
cases  deaths  which  have  been  attriltiitcd  to  ether  and  other  anajsthetics 
have  been  in  fact  tlue  to  the  alcohol  whicii  has  been  given  to  the  patient; 
and  it  seems  to  me  an  unalterable  rule  of  practice  that  no  alcohol  should 
C-ver  be  given  to  the  patient  suffering  from  anaesthetic  cardiac  failure.  If 
in  the  course  of  the  ansesthesia  cardiac  failure  results  from  hemorrhage 
or  other  surgical  cause,  alcohol  may  seem  to  some  surgeons  to  be  indi- 
cated, but  under  these  circumstances  any  gtxjd  effect  which  would  l)e 
obtained  by  alcohol  would  be  more  rapidly  reached  by  the  further 
administration  of  ether. 

The  effect  of  ammonia  upon  the  failing  heart  of  chloroform  anaes- 
thesia has  been  in  my  experiments  uncertain — sometimes  distinct,  some- 
times very  fugacious,  sometimes  iniperccjitible.  Twenty  cubic  centimetres 
of  a  10  per  cent,  solution  of  aqua  ammoni;e  fortior  (U.  S.  Pharmacopceia) 
injected  into  a  vein  in  the  aniesthetized  dog  did  sometimes  produce  an 
immediate  rise  in  the  arterial  pressui-e,  and  even  fugaciously  register 
itself  in  the  respiratory  rate,  but  perhaps  more  fretjuently  it  failed  in  its 
influence. 

The  influence  of  injections  of  digitalis  has  been,  in  a  munber  of  exper- 
iments, very  pronounced  in  causing  during  aniesthesia  in  the  dog  a  per- 
sistent gradual  rise  of  the  arterial  ]>ressure  with  an  increase  in  the  size 
of  the  individual  pulse-beats.  In  several  instances  death  was  apparently 
averted  by  its  injection,  and  I  saw  in  one  or  two  experiments,  in  which 
large  amounts  of  the  digitalis  had  been  employed,  sudden  systolic  cardiac 
arrest,  indicating  that  digitalis,  if  in  sufficient  amount,  is  able  to  assert 
itself  victoriously  in  opposition  to  chloroform.  Moreover,  when  I  have 
given  chloroform  to  dogs  whose  hearts  were  already  under  the  influence 
of  digitalis  there  has  seemed  to  be  a  peculiar  steadying  or  sustaining 
power  combating  the  circulatory  depression  naturally  produced  by  the 
amesthetic,  and  I  believe  that  in  all  cases  of  weak  heart  in  man  a  full 
dose  of  digitalis  given  hypodermicallt/  before  the  administration  of  chlo- 
roforiii  would  greatly  lessen  the  danger  of  cardiac  collapse. 

With  amyl  nitrite,  for  which  much  has  been  claimed  as  a  cardiac 
stimulant,  I  was  never,  in  my  experiments,  able  to  obtain  any  rise  of 
the  arterial  pressure,  and  very  rarely  any  alteration  in  the  size  of  the 
pulse-wave  ;  occasionally  the  pulse-wave  did  appear  to  be  a  little  fuller. 
My  own  belief  is  that  the  amyl  nitrite  is  a  doubtful  i-emedy  '\\liich 
must  be  used  with  the  greatest  caution  in  ana?stlietic  syncope  ;  certainly 
the  least  overdose  most  seriously  adds  to  the  dej^ression  of  the  heart. 

Of  all  the  experimental  results  ^vhich  I  reached,  those  with  strych- 
nine were  to  me  the  most  surprising.  I  found  that  the  injection  of 
strychnine  into  the  jugular  vein  of  a  dog  whose  circulation  and  respira- 
tion were  failing  from  an  overdose  of  chloroform  was  usually  followed 
by  a  gradual  rise  of  the  arterial  jiressure,  and  always  by  an  immediate 
and  extraordinary  increase  of  the  rate  and  depth  of  the  respiration.  Thus 
I  have  seen  a  respiration  which  had  [>ractically  ceased  for  ten  seconds, 
under  the  influence  of  the  injection  of  strychnine  become  at  once  very 


ADMINISTRATION.  675 

large  and  full  and  reach  the  rate  of  130  a  minute.  In  order  to  get  any 
effect  from  the  alkaloid,  however,  it  is  essential  to  give  it  in  large  doses ; 
to  a  robust  adult  with  serious  anesthetic  heart  or  respiratory  failure  -^ 
of  a  grain  may  be  given  at  once  hypodermically. 

I  have  never  performed  any  experiments  to  determine  the  effects  of 
cocaine  in  anfesthesia,  but  I  have  proven  it  to  be  one  of  the  most  pow- 
erful of  the  respiratory  stimulants,  and  that  it  is  also  able  to  act  as  an 
adjuvant  to  strychnine,  so  that  in  the  cliloralized  dog,  wlien  the  respira- 
tion has  bci'n  raised  as  far  as  could  be  done  with  strychnine  without 
incurring  too  much  risk  of  poisoning,  cocaine  was  able  still  further  to 
improve  it.  I  believe,  therefore,  that  hypodermic  injections  of  strychnine 
and  cocaine  woukl  act  more  effectually  in  the  accidents  of  aniesthesia 
than  would  either  alkaloid  by  itself. 

The  most  rcmarkal)le  results  whicli  I  liave  reached  in  bringing  about 
recovery  of  animals  to  all  ordinary  intents  and  purposes  dead  were 
obtained  through  the  use  of  artificial  respiration.  Thus  I  have  seen  an 
animal  in  which  no  respiratory  movements  whatever  had  taken  place 
for  two  minutes,  and  in  which  during  that  time  no  movements  of  blood 
had  occurred  in  the  carotid  artery,  and  in  wiiicii,  therefore,  tiie  heart 
liad  practically  ceased  to  beat,  rapidly  and  jjermanently  restored  by 
artificial  resj)iration.  I  have  no  doubt  that  in  a  large  proportion  of  the 
deaths  which  have  occurred  in  man  from  antesthesia  the  fotal  result 
might  have  been  avoided  by  the  use  of  an  active  artificial  respiration. 
The  difficulty  with  artificial  respiration,  as  it  has  been  hitherto  practised 
upon  man  after  the  Sylvester  or  other  methods,  is  its  inefficiency ; 
whereas  the  artificial  respiration  of  the  pliysit)logical  laboratory  is 
much  more  efficient  than  natural  breathing  in  causing  circulation  of  air 
through  the  lungs,  and  therefi)re  in  removing  excess  of  the  anajsthetic 
from  the  residual  air  in  the  lungs  and  from  the  blood.  The  use  of  what 
may  be  called  "  forced  "  artificial  respiration  by  the  physiologist  so  natu- 
rally suggested  a  similar  practice  in  man  that  the  celebrated  John  Hunter 
invented  for  the  jmrpose  an  apparatus  which  consisted  of  a  Ijcllows  so 
constructed  that  when  it  was  extended  one  compartment  drew  in  air 
from  the  lungs,  whilst  the  other  drew  air  from  the  atmosphere,  and 
when  it  was  closed  the  process  was  reversed,  the  fresh  air  being  thrown 
into  the  lungs,  the  foul  air  into  the  atmospliere. 

There  is,  however,  no  need  of  drawing  the  air  out  of  the  fully-filled 
lungs ;  the  chest-walls  even  after  death,  nuich  more  during  life,  have 
sufficient  elasticity  to  force  the  air  out  of  the  lungs,  and  all  ordinary 
laboratory  apparatus  for  artificial  respiration  is  based  upon  this  fact. 
For  forced  artificial  respiration  upon  man  an  ordinary  bellows  is  all 
that  is  requir(>d  for  the  motive  power.  In  1887,  Dr.  George  E.  Fell  of 
Buffalo  introduced  the  use  of  forced  respiration  to  the  profession  as  a 
means  of  treating  morphine-poisoning,  and  devised  an  apparatus  which 
consists  of  a  pair  of  foot-bellows  liv  which  air  is  forced  into  a  receiving 
chamber,  which  in  turn  is  connected  with  an  apparatus  for  warming  the 
air,  and  a  valve  which  can  be  opened  and  shut  by  a  movement  of  the 
finger.  This  valve  in  turn  leads  to  the  tracheal  tube.  When  the  valve 
is  opened  the  air  rushes  through  the  chamber  into  the  lungs  and  exjiands 
them  ;  the  finger  is  lifted,  the  valve  shuts,  the  lungs  contract ;  and  so 
the  respiration  goes  on.     I  have  no  doubt  that  this  apparatus  is  very 


67G  ANESTHESIA. 

efficient  in  practice,  but  it  seems  to  me  to  be  open  to  the  serious  oI)j('('- 
tion  of  being  unnecessarily  com])lex  and  costly.  A  much  cheaper, 
simpler,  and  probably  e(|ually  efficnent  ajiparatus  may  consist  simply  of 
a  ])air  of  bellows  of  proper  size,  a  few  feet  of  india-rubber-tubing,  a 
face-mask,  and  two  sizes  of  intubation-tubes  ;  there  should  also  be  set 
in  tile  rubber  tubing  a  metal  tube,  similar  to  the  ti'aciieal  cauula  of  the 
physiological  laboratory,  so  that  it  is  in  the  power  of  the  operator  to 
allow  for  the  escape  of  any  excess  of  air  thrown  by  the  bellows.  I 
suppose  this  whole  apparatus  could  be  prepared  at  the  expense  of  less 
than  five  dollars,  and  it  seems  hardly  necessary  to  point  out  its  probable 
value,  not  only  in  narcotic  poisonings,  but  in  all  accidents  or  diseases  in 
which  life  is  threatened  by  a  temporary  paralysis  of  the  respiratory 
centres. 


THE  TECHNIQUE  OF  ANTISEPTIC  AND 
ASEPTIC  SURGERY. 

By  ABPAD  G.  GERSTER,  M.  D. 


I.  Infection,  its  Agents  and  Carriers. 

Modern  surgery,  as  uuderstood  and  practised  to-day,  has  been  made 
possible  by  two  thinus.  One  was  the  discovery  of  antesthesia  ;  the  otiier, 
the  firm  estal)lishment  of  the  Listerian  principle  of  snrgical  cleanliness. 
The  changes  bronght  about  by  tiie  general  acceptance  of  the  Listerian 
principle  are  rarely  realized  by  that  younger  generation  of  surgeons 
whose  medical  education  was  finished  after  1885.  The  terrors  of  the 
surgical  practice  of  those  former  days — terrors  which  surgeon  and  patient 
faced  meekly  and  in  resigned  despair — ^such  as  unavoidable  sui)puration, 
pyajmia,  septicaemia,  erysipelas,  tetanus,  and,  worst  of  all,  hospital  gan- 
grene, are  so  rare  now  that  some  of  them,  notably  hospital  gangrene, 
may  safely  be  declared  to  be  extinct.  All  of  them  are  looked  upon 
now  as  exceptional  and  always  due  to  ascertainable  and  avoidable  con- 
ditions. Hence,  even  suppuration  not  being  considered  an  unavoidable 
but  rather  an  unusual  conn)lication,  the  possibility  of  its  occurrence  is 
allotted  a  diminishing  share  in  the  determination  of  the  advisability  of 
all  oj)crations. 

Adequately  to  point  out  the  enormous  practical  gain  due  to  mod- 
ern methods  as  compared  with  pre-Listerian  results,  it  may  suffice  to 
state  that,  according  to  Lind]>aintncr,'  "80  per  cent,  of  all  wounds" — 
treated  in  Nussbaum's  clinic  in  Munich — "  were  attacked  by  hospital 
gangrene.  Erysipelas  was  tiie  order  of  the  day  to  such  an  extent  that 
its  occurrence  could  almost  have  been  looked  u])on  as  tlic  normal  course  ; 
not  to  suture  any  scalp-wound  was  a  firm  princijile  ;  healing  by  primary 
union  did  not  exist,  and  suturing  of  a  wound  would  have  simply  led  to 
retention  and  the  further  encouragement  of  erysi])elas.  Within  one 
year  1 1  out  of  1 7  patients  subjected  to  amputation  died  of  pyemia ;  to 
observe  the  course  uf  a  compound  fracture  was  a  great  rarity  in  our 
clinic,  as  it  was  customary  to  perform  amputation  immediately,  other- 
wise purulent  infection,  hos]>ital  gangrene,  or  septicaemia  led  to  a  fatal 
termination  within  a  few  chiys."  In  Volkmann's  clinic  at  Halle  the 
usual  rate  of  mortality  in  compound  fracture  was  40  per  cent. 

To  illustrate  by  American  examples  we  may  mention  that  Ashhurst" 
in  1881  gives  a  rate  of  mortality  of  28  per  cent,  after  100  major  ampu- 
tations performed  by  iiimsclf,  judging  this  to  be  below  the  general 
average,  which  was  al)out  33  per  cent. 

^Deutsche  Zeitschrift  fiir  Chirurf/ie,  1S77. 
^  Encyclopedia  of  Surgery,  vol.  i.  p.  G17. 

677 


678     THE  TECHNIQUE  OF  ANTISEPTIC  AND  ASEPTIC  SURGERY. 

What  a  change  has  taken  ])hu'0  since  then  is  attested  by  the  reniari?- 
able  improvement  in  the  dcatii-rate  after  all  forms  of  o])erativc  work. 
To  give  an  instance,  it  may  be  stated  that  of  318  major  amj)ntations 
done  by  Volkmann  under  antiseptic;  precautions,  28  cases  ended  fatally  ; 
that  is,  his  rate  of  mortality  was  about  S)  per  cent.'  Still  another  and 
more  forcible  illustration  of  the  influence  of  antiseptic  jirinciple.s  is  the 
report  (»f  Dennis  conipi'ising  1000  cases  of  compound  fracture  treated 
by  him  in  four  large  metropolitan  iiospitals,  covering  a  period  of  several 
years,  with  a  death-rate  from  se[)tico-jiyiemia  of  \  of  1  ])er  cent.  This 
is  in  marked  contrast  to  the  published  report  in  pre-antiseptic  days  of 
the  Obuchow  Hospital  of  St.  Petersburg,  where  the  death-rate  reached 
as  high  as  68  per  cent,  in  106  cases  of  compound  fractures;  or  of  the 
Pennsylvania  Hospital  from  18.'31  to  1851,  where  the  death-rate  was  44 
per  cent,  in  116  cases;  or  of  the  New  York  Hospital  during  the  same 
period,  where  the  mortality  was  48  per  cent,  in  126  cases." 

A  corresponding  improvement  is  observable  in  all  other  branches  of 
surgery.  The  lai-ge  cavities  of  the  human  body  are  fearlessly  invaded 
now,  the  cranial  contents,  the  pleura,  peritoneum,  or  large  joints  form  no 
more  a  noli  me  tangerc,  and  what  used  to  be  called  the  surgeon's  "  luck" 
or  "misfortune"  is  now  considered  to  be  the  direct  consequence  of  a 
sound  or  of  an  improper  tecliniipic  of  cleanliness. 

In  another  direction  great  progress  for  the  better  has  been  secured, 
materially  affecting  the  welfare  of  patients  and  hospital  economics,  inas- 
much as  the  average  duration  of  time  needed  for  curing  most  surgical 
complaints  requiring  operation  has  been  materially  reduced,  To  give  a 
typical  illustration,  it  may  suffice  to  say  that  where  in  former  days  three 
to  six  months  were  consumed  in  healing  the  wound  after  ablation  of  the 
mamma,  two  to  four  weeks  are  at  present  amply  sufficient  for  the  purpose. 

It  is  a  matter  of  curious  interest  to  see  the  laborious  compilation  of 
statistical  tables  contained  in  many  of  the  older  works  on  surgery,  in 
which  the  influence  of  the  external  temjierature,  the  seasons,  barometric 
pressure,  sex,  nationality,  or  race  exerted  ujjon  the  success  of  operations 
is  seriously  considered.  We  kno^v  to-day  that  the  healing  of  a  wound 
is  entirely  uninfluenced  by  these  as  well  as  b}'  other  factors  formerly  con- 
sidered important,  such  as,  for  instance,  constitutional  taint  or  individual 
predisposition.  This  change  for  the  better  is  solely  due  to  our  know- 
ledge that,  like  fermentation  and  jiutrefoction,  the  infection  of  wounds  is 
directly  due  to  the  importation  anil  ])roliferation  of  minute  organisms. 
Protect  the  wound  from  these  organisms  and  it  will  heal  kindly  in  a 
tuberculous,  syphilitic,  or  cancerous  subject  in  man  and  woman,  in  the 
young  and  old. 

a.  Atmospheric  and  Contact  Infection. — The  belief  that  the 
air  may  be,  and  often  is,  the  medium  of  the  transportation  of  morbid 
agents  is  as  old  as  human  tradition.  The  knowledge  that  the  course  of 
subcutaneous  injuries  is  widely  diiferent  from  that  of  open  wounds  was 
clearly  expressed  by  John  Hunter,  since  whose  time  it  has  assumed  the 
character  of  a  surgical  tenet.  Yet  the  nature  of  the  precise  agent  con- 
tained in  the  atmospheric  air,  and  notoriously  injurious  to  Avounded 
tissues,  remained  a  mystery.     INIalgaigne's  experiment  of  pumping  the 

'  Oberst:  Die  Amputationen,  etc.,  Halle,  1882. 
2  Philad.  Medical  News,  April  19,  1890. 


INFECTION,  ITS  AGENTS  AND   CARRIERS  679 

subcutaneous  tissue  of  animals  full  of  atmospheric  air,  thus  rendering 
them  emphysematous,  then  fraeturinu;  bones,  dividing  subcutaneously 
tendons,  etc.,  without  producing  suppuration,  only  served  to  thicken  the 
mystery. 

It  is  Lister's  immortal  merit  to  have  directed  surgical  endeavor  into 
the  I'ight  channels  in  utilizing  the  hints  afforded  by  the  labors  of  Pasteur 
and  others.  He  showed  that  the  decomposition  (if  dead  organic  sub- 
stances is  due  not  to  the  gaseous,  but  to  accidental  and  corpuscular, 
elements  floating  in  the  air.  As  a  direct  outcome  of  the  theory  that 
disturbances  in  the  healing  of  a  wound  were  produced  by  a  sort  of  fer- 
mentation analogous  with  the  decomposition  observed  in  dead  organic 
matter,  leister  endeavored  to  destroy  tlie  nocuous  contents  of  the  air  by 
the  use  of  his  carlxtlic  spray,  and  sought,  further,  to  prevent  the  ingress 
of  these  organisms  into  tlie  wounds  by  the  emj)loyment  of  various  occlu- 
sive measures,  the  tinal  form  of  which,  the  typical  Lister  dressing,  revo- 
lutionized surgery.  Though  the  theory  lacked  scientific  confirmation, 
the  enormous  improvement  of  the  results  of  surgical  operations  done 
under  Lister's  precautions,  as  compared  with  former  ones,  was  very  appa- 
rent to  candid  oliservers. 

The  fierce  and  unphilosophical  opposition  of  Lister's  countrymen  did 
not  prevent  ^'olkmann  from  studying  and  benefiting  by  the  new  light 
issuing  from  Scotland,  and  to  his  unreserved  and  generous  approbation 
is  due  the  rapid  acceptance  of  Lister's  principle  throughout  Germany, 
the  continent  of  Europe,  and  America.  To  England  belongs  the  doubt- 
ful distinction  of  harboring  the  last  reiunants  of  a  truculent  negation  of 
M'hat  tlie  grateful  world  has  learned  to  value  as  a  great  benefaction  to 
suffering  humanity. 

As  before  mentioned.  Lister's  theory  lacked  scientific  proof  long  after 
its  great  utility  had  been  abundantly  proven  in  surgical  practice.  The 
actual  scientific  demonstration  of  the  micro-organisms  causing  wound- 
infection,  their  separation  and  classification  by  secondary  culture,  in 
short,  their  natural  history,  are  the  outcome  of  the  methods  of  research  orig- 
inated by  Robert  Koch,  who  furnisjied  the  long-lacking  scientific  proof 
of  the  correctness  of  the  Listerian  theory. 

Bacteriology  has  shown  that  the  air  contains  various  micro-organisms 
in  varying  proportions  and  quantities,  the  variations  being  veiy  great 
under  different  circumstances.  AVhile  l)acteria  and  cocci  prevail  in  the 
air  of  inhabited  dwellings,  the  spores  of  mould  and  the  fungi  of  alcoholic 
fermentation  firm  the  majority  of  the  micro-organisms  contained  in  the 
open  air. 

We  know  that  the  air  of  cities  contains  more  germs  than  that  of  the 
country ;  that  in  diy  weather  there  are  more  germs  floating  in  the  air 
than  in  rainy  weather;  and  that  tlie  air  carries  more  germs  when  there 
is  wind  than  wiien  it  is  calm.  The  air  in  mid-ocean,  on  top  of  the  highest 
mountains,  and  in  the  middle  of  large  tracts  of  uninhabited  damp  forests 
is  practically  germ-free.  A  sea-breeze  carries  fewer  germs  than  a  land- 
breeze.' 

These  facts  point  irresistibly  to   the  assumption,   now  abundantly 

'  Condorelli-Mangeri :  "  Variazioni  numeriche  dei  micro-organismi  nell'  aria,  etc.," 
Atli  deW  Acarleynia,  etc.,  Catania,  1888,  Ser.  iii.  T.  xx. ;  Uffelmann :  "  Luftuntersuchun- 
geii,"  Arcli.fiir  Hygiene,  Bd.  viii.,  1888,  p.  262. 


680     7-/77?  TECHNIQUE  OF  ANTISEPTIC  AND  ASEPTIC  SURGERY. 

proven,  that  tlic  nidus  of  all  minute  orfjanit^ms  i.s  not  the  air — that  they 
are  not  bred  in  the  air,  as  formerly  believed,  but  that  their  breeding- 
places  are  to  be  looked  for  in  organie  substances,  mainly  on  the  surliiee 
of  the  earth,  whence  they  are  occasidually  and  temjK)rarily  displaced  to 
float  in  the  air.  As  soon  as  the  disturbing  agents  subside  the  tldating 
germs  will   settle   back  on   the  surtace. 

(Jrganic  germs  \\\\\  best  float  in  air  when  they  assume  the  form  of  dry 
powder  or  of  dust ;  and  Naegeli  has  demonstrated  that  they  will  never 
enter  the  air  from  fluid  media  by  the  instrumentality  of  ordinary  agents, 
such  as  common  winds  or  drafts  of  air.  Hence  the  belief  that  sewer-gases 
may  cause  infectious  diseases  is  erroneous,  as  the  stinking  air  of  a  damp 
sewer  contains,  as  a  rule,  fewer  germs  tiian  the  best  ventilated  or  unven- 
tilated  dwelling  or  the  open  street.  To  become  dangerous  the  contents 
of  the  sewer  or  water-closet  must  be  first  dried,  then  pulverized,  and 
finally  wafted  in  air.'  It  may  be  added  that  micro-organisms  may  be 
carried  from  liquid  media  into,  and  remain  susjiendcd  in,  the  atmosphere 
by  inordinately  strong  winds,  .such  as  prevail  during  storms.  This  is 
explained  by  the  tendency  of  strong  winds  to  dash  water  against  shores, 
to  make  the  waves  break,  and  thus  to  produce  spray,  which  is  readily 
transported  by  high  winds.^ 

In  further  confirmation  of  the  fact  that  dryness  and  agitation  of  the 
air  favor  the  increase  of  the  number  of  micro-organisms  contained  in  it, 
may  be  mentioned  the  facts  that  C'ondorelli-Mangeri  found  in  the  air  of 
Catania  a  decided  increase  of  germs  at  times  when  a  fair  or  otiier  popular 
gathering  was  held.  The  relative  number  of  germs  will  rapidly  increase 
in  the  air  of  workshops  after  work  has  commenced,  and  the  same  thing 
is  observed  as  to  the  air  of  barracks,  Iiospital  wards,  and  dwellings  shortly 
after  their  Iieing  sMcpt  and  dusted.  Accoi'ding  to  Hesse,  in  the  air  of 
school-rooms,  originally  containing  3000  germs  per  cubic  metre,  their 
number  will  increase  to  20,000  during  school-hours,  and  to  40,000  when 
the  children  leave  school. 

It  is  of  considerable  interest  to  note  that  the  breath  of  healthy  and 
diseased  animals  or  human  beings,  be  it  however  foul,  has  never  been 
found  to  contain  micro-organisms.  The  moist  surfaces  of  the  bronchi 
and  lungs  act  as  a  filter  by  which  germs  carried  into  the  respiratory  tract 
are  retained,  the  expired  air  being  almost  entirely  free  from  germs.^ 

Thus  we  find  that  all  microbes  foiind  suspended  in  air  are  derived 
from  the  exposed  surfaces  of  organic  material.  In  examining  the  relative 
proportion  of  living  germs  contained  in  sputa,  pus,  street-dirt,  slops,  and 
the  water  of  open  sewers  and  canals  we  encounter  truly  apjialling  quan- 
tities, and  far  outnumbering  anj-thing  ever  found  in  the  foulest  atmo- 
sphere. According  to  the  researches  made  by  the  Berlin  Hygienic 
Institute,  each  cubic  centimetre  of  the  water  of  the  river  Spree  contains 
from  3200  to  154,000  germs,  the  average  being  37,525.^  There  are  in 
each  drop  of  pus  millions  of  microbes,  and  similar  proportions  prevail  as 
to  every  kind  of  decomposing  organic  material,     t om])arcd  \\ith  tlii.?, 

'  Petri :  "  Eine  neue  Metliode,  Bacterien-Polvsporen,  etc.,"  Zeitsclirifl  J'iir  Hygiene,  1888. 
'  Fontin  :    Wratsch,  1888,  Nos.  49  and  50. 

'  Strauss :  "  Sur  I'absence  des  microbes  dans  I'air  expire,"  Annates  de  I' Inst.  Pasteur, 
1888,  p.  304. 

'  Scliimmelbusch :  Aseptische  Wundbehandlung,  p.  13. 


INFECTION,   ITS  AGENTS  AND  CARRIERS.  681 

the  40,000  germs  found  in  a  eul)ic  luetre  of  the  vitiated  air  of  a  lecture- 
room  are  truly  iusignifieant. 

With  these  facts  in  view,  the  statement  may  readily  he  accepted  that 
contact  of  a  wound  with  any  of  these  substances  will  involve  a  much 
greater  chance  of  infection  than  exposure  to  atmosplieric  air.  And  long 
before  actual  proof  of  these  relations  existed,  the  I'esults  of  actual 
practice  had  demonstrated  tliat  Lister's  fears  of  aerial  infection  were 
exaggerated.  Hence  the  early  abantlonment  of  the  carbolic  spray  and 
the  later  one  of  irrigation.  The  only  precaution  worth  taking  against 
the  possibility  of  atmospheric  contamination  of  a  wound  is  the  avoidance 
of  acts  tending  to  stir  up  dnst.  iS\\ee})ing,  dusting,  and  ventilating  of 
localities  to  l)e  shortly  used  for  operative  work  is  ini]>roper.  These  pro- 
cedures should  be  gone  through  with  far  enough  ahead  of  the  time  of 
operation  to  permit  the  laying  of  the  particles  of  dust  before  the  opera- 
tion begins.  Should  time  be  lacking  to  fulfil  this  condition,  it  will  be 
best  not  to  disturb  any  hanging  or  piece  of  furniture,  not  to  open  doors 
and  windows  simultaneously  ;  in  short,  to  avoid  everything  tending  to 
stir  uj)  dust. 

b.  Infective  Agents. — As  the  sulyect  of  surgical  bacteriology  has 
received  adequate  treatment  in  the  preceding  articles  of  this  work,  it  will 
be  sufficient  to  point  out  the  jjractical  outcome  of  the  labors  of  the  bac- 
teriologist as  far  as  they  concern  the  surgeon.  Though  it  is  known  that 
certain  sul)stances,  organic  and  inorganic,  injected  into  living  animal 
tissues,  are  apt  to  cause  a  i>rocess  similar  to  microbial  sup])uration,  it  is 
just  as  well  known  that  this  manner  of  causation  is  very  rare,  and  in  no 
wise  comparable  as  to  frequency  and  general  importance  with  the  forms 
of  progressive  suppuration  directly  dependent  upon  the  action  of  the 
various  pyogenic  micro-organisms.  The  overwhelming  majority  of  sup- 
purations, and  other  disturbances  of  a  similar  natui'e  to  which  the  human 
tissues  are  subject,  certainly  depend  upon  the  direct  influence  of  patho- 
genic germs  imported  from  without.  Their  proliferation  and  the  kical 
and  general  etiect  of  their  products  constitute  what  are  termed  "  infec- 
tion "  and  "  disease ; "  that  is,  a  progressive  development  of  symptoms 
well  defined  and  typical.  Tliis  progressive  character  of  the  symptoms 
accompanying  tiie  lodgement  and  proliferation  of  jiathogenic  organisms 
in  the  living  tissues  is  what  distinguishes  an  infectious  process  from  other 
processes  similar  to,  but  essentially  different  from,  the  former,  and  pro- 
duced by  chemical,  mechanical,  or  caloric  agencies. 

With  a  full  understanding  of  the  overwhelming  importance  of  the 
microbial  factor  in  producing  certain  morbid  states,  it  would  yet  be  one- 
sided to  attribute  the  production  of  these  morbid  conditions  to  the  pres- 
ence of  microbes  alone,  and  to  nothing  else.  Altliough  we  admit  that 
ordinarilv  tliere  canntjt  lie  suppuration  without  microlics,  we  know,  on 
the  other  hand,  that  the  j)resence  of  microlies  in  itself  will  often  fail  to 
cause  suppuration  unless  the  state  of  the  tissues  themselves  or  the  general 
state  of  health  favors  their  germination.  In  M'hat  this  predisposition  of 
certain  tissues  of  a  body  consists  we  do  not  know ;  nor  can  ^ve  positively 
define  wliy  tlie  s;ime  individual  will  show  different  degrees  of  resistance 
to  the  same  form  of  infection  at  different  times.  So  much,  however,  is 
fairlv  certain,  that  to  account  for  tlie  various  forms  of  microbial  infec- 
tion we  nuist  assume  two  nearly  etpially   important  factors  :  First,  the 


682     THE  TECHNIQUE  OF  ANTISEPTIC  AND  ASEPTIC  SURGERY. 

lodgemont  of  pathogenic  organisms  within  the  living  tissues ;  and,  sec- 
ondly, a  condition  of  these  tissnes  favorable  to  the  development  and 
multiplication  of  microbial  growth.  To  illustrate  this  relation  of  things 
it  may  suiiice  to  mention  the  marked  predisposition  to  suppurative  pro- 
cesses observed  in  diabetes  mellitus. 

n.  Disinfection  and  Sterilization. 

Foremost  among  the  means  for  disinfection  stand  the  homely  but 
thoroughly  efficient  and  sound  methods  of  mechanical  pin-ificafion,  as, 
for  instance,  maceration,  scrubbing,  washing,  scraping,  shaving,  M'ith  or 
without  the  aid  of  emollients,  among  which  the  jirincipal  one  is  soap. 
Being  aware  of  the  fact  that  the  sparse  number  of  infectious  germs  con- 
tained in  the  air  is  far  outnumbered  by  the  millions  of  microbes  incor- 
porated \\ith  the  various  forms  of  gross  filth  and  dirt  adherent  to  almost 
every  surfoce  exposed  to  contact  with  the  outer  world,  our  princijial 
endeavor  at  disinfection  must  be  directed,  in  the  first  place,  toward  the 
removal  of  these  gi'oss  lumps  of  filth.  How  much  can  be  acconn)lished 
in  surgery  by  means  of  these  simple  methods  was  first  demonstrated  by 
the  brilliant  results  of  men  like  Lawson  Tait,  whose  reliance  was  placed 
almost  exclusively  upon  ordinary  measures  of  personal  and  domestic 
cleanliness.  The  mechanical  removal  of  the  great  bulk  of  microhicd  dirt 
from  the  objects  to  be  bn)Ught  in  contact  \\ith  a  wound  i.s  the  mod  im- 
portant preparatory  act  of  all  forms  of  disinfection. 

Methods  of  chemical  disinfection  have  undergone  manifold  changes 
since  the  davs  of  the  universal  reign  of  carbolic  acid.  Formerly,  some 
deodorizing  agents  were  considered  good  disinfectants,  and  the  valuation 
of  the  merits  of  the  various  disinfectants  was  extremely  uncritical.  We 
owe  the  more  correct  appreciation  of  the  value  of  these  substances  to  the 
labors  of  Koch,  who  by  pure  culture  taught  us  to  isolate  the  several 
species  of  pathogenetic  germs,  and  showed  us  how  to  recognize  their  dif- 
ferent vegetative  forms. 

Some  of  these  microbes  are  jiroductive  of  spores  ;  others  are  sporeless. 
In  general,  it  may  be  said  that  the  spores  of  micro-organisms  offer  a 
much  greater  resistance  to  disinfecting  agents  than  the  mother-plant, 
and,  furthei-more,  it  was  learned  that  the  ditferent  species  of  microbes 
also  differ  from  each  other  materially  in  this  respect. 

In  estimating  the  bactericidal  value  of  a  chemical  disinfectant  a 
number  of  precautions '  have  to  be  observed  to  eliminate  errors,  and  dis- 
crimination must  be  used  in  ajijilying  the  results  thus  gained  to  the 
actual  conditions  met  with  by  the  sui-gcon  in  his  practice. 

Another  factor  materially  influencing  the  development  of  microbes 
is  the  presence  or  absence  of  certain  cardinal  conditions  necessary  for 
their  proliferation.  A  suitable  pabulum,  a  certain  quantity  of  moisture, 
and  a  certain  temperature  are  indispensable.  Withdraw  one  or  more  of 
these  conditions,  and  the  microbes  u-ill  either  jierish  or  their  grorrth  will  be 
retarded. 

For  ascertaining  the  relative  value  of  a  number  of  the  common  dis- 
infectants, as  to  their  power  of  retarding  bacterial  growth,  Koch  selected 
the  spores  of  the  anthrax  bacillus,  one  of  the  most  resistant  forms  of 
'  Geppert :  "Zur  Lehre  von  den  Antisepticis,"  Bed.  Icliu.  Woclienschrift,  1889,  No.  36. 


DISINFECTION  AND  STERILIZATION. 


683 


pathogenetic  bacteria.     The  results  of  his  investigation  are  contained  in 
the  following  table  : 


In  the  proportion  of— 


Bichloride  of  mercury 
Oil  of  niiistard  ... 
Arseniate  of  potash  . 

Thymol       

Oil  of  turpentine      .    . 

Osmicacid 

Oil  of  cloves  .... 

Potash  soap 

Iodine     ...        .    . 
Salicylic  acid     ... 

Camphor 

Eucalyptol 

Borax      

Benzoic  acid 

Bromine 

Chlorine 

Permangan.  potash   . 

Boracic  acid 

Carbolic  acid      .    .        . 

Quinine      

Chlorate  of  potash    .    . 

Alcohol       

Cooking  salt 


Growth  markedly 
checked. 

Entire  cessation 
of  growth. 

1,600,000 

333,000 

100,000 

80,000 

75,000 

1 
1 
1 

300,000 
33,000 
10,000 

6,000 
5,000 

5,000 

5,000 
3,300 
2,500 
2,500 
2,000 
2,000 

1 

1 
1 

1 
1 

1,000 
1,500 
1,250 
1,000 
700 

1,500 

1,500 

1,400 
1,250 

1 

800 

1,250 

1 

850 

830 

1 

625 

250 

100 

1 

12.5 

04 

It  is  well  to  remember  that  this  table  shows  only  the  effect  of  a  nnmber 
of  chemicals  as  to  their  influence  in  retarding  ov  checking  the  germination 
of  anthrax  spores,  and  not  at  all  their  capacity  of  killing  these  s])ores. 
It  is  much  easier  to  clieck  the  growth  of  bacteria  than  to  kill  tiiem, 
especially  to  kill  them  within  a  few  minutes,  which  is  an  es.sential  con- 
dition of  the  ])ractical  utility  of  a  germicidal  agent. 

The  most  important  of  all  bactericidal  agents,  because  easily  pro- 
cured, rapidly  effective,  and  practical,  is  heat.  It  can  be  used  in  the 
form  of — 

1.  The  actual  cautery ; 

2.  Boiling  water ; 

3.  Steam  ; 

4.  Hot  air. 

The  actual  cautery  is  one  of  the  most  ancient  and  most  effective  dis- 
infectants. It  must  suffice  merely  to  mention  it  here,  as  it  properly 
belongs  to  the  subject  of  o))crative  technique. 

Of  the  other  agents,  boiling  wafer  deserves  to  be  placed  first  of  all. 
^.s  to  its  bactericidal'  value,  it  is  known  that  it  icill  kill  spores  of  anthrax 
in  two  minutes,  and  will  destroy  the  vegetative  forms  of  any  coccus  or 
bacteria  in  from  one  to  five  seconds. 

Next  in  importance  is  steam.,  which,  to  be  ftdly  effective,  must  not  be 
mixed  witii  air,  but  ought  to  be  pure  and  "  saturated."  Steam  can  be 
used  in  several  ways,  vithev  quiescent  ov  moving;  it  can  be  used  under 
increased  pressure  or  superheated.  Of  tiiese  several  forms,  moving  steam 
has  been  found  most  useful,  and  it  will  kill  anthrax  spores  in  from  five  to 
fifteen  minutes. 


684     THE  TECHNIQUE  OF  ANTISEPTIC  AND  ASEPTIC  SURGERY. 

Less  t'flw^tivc  tli;iii  stc;iMi  is  hot  :iir,  to  which,  at  a  temperature  of  140° 
Celsius,  spores  will  siicciinih  only  alter  an  exposure  of  three  honvs. 
Anotiier  great  drawbaek  of  hot  air  is  its  great  inferiority  of  'penetration 
as  compared  with  lioiiing  water  and  flowing  steam.' 

The  badericklal  value  of  the  commonly  employed  cheniieals  of  sur- 
gery falls  far  below  that  of  the  caloric  agents  just  enumerated.  There 
are  \evy  few  chemicals  which  even  in  a  concentrated  state  will  destroy 
anthrax  spores  within  twenty-lour  hours.    Of  these  may  be  mentioned — 

Bichk>ride  of  mercury, 

Iodine, 

Chlorine, 

Bromine, 

Trichloride  of  iodine, 

Cresol  mixed  with  sul|)luu'ic  acid. 

Of  chemicals  that  require  a  nuich  longer  time  to  kill  anthrax  spores 
there  are — 

Carbolic  acid,  5  :  100. 

Creoline, 

Ligneous  vinegar,  2  days. 

Chlorate  of  lime,  5  :  100,  5    "' 

Turjientine,  " 

Formic  acid,  " 

Chloride  of  iron,  5:  100,         " 

Quinine  mur.,  1  :  100,     10    " 

Arsenious  acid,  1  :  1000,         " 

Muriatic  acid,  2  :  100,  " 

Ether,  sulphuric,  30    " 

Among  substances  that  even  after  months  have  exerted  no  influence 
whatever  upon  the  vitality  of  the  spores  of  the  bacillus  of  anthrax,  there 
are — 

Absolute  alcohol. 

Distilled  M'ater, 

Chloroform, 

Glycerin, 

Benzoic  acid. 

Ammonia, 

Concentrated  solution  of  cooking  salt, 

Chlorate  of  potass.  (5  :  100), 

Alum, 

Borax. 

These  lists  demonstrate  the  remarkable  insisting  power  of  spores  to  the 
various  chemical  disinfectants.  The  vegetative  forms  of  pathogenetic  micro- 
organisms, the  bacilli  and  cocci,  show  a  much  lower  degree  of  vitality, 
and  w  ill  more  easily  succumb  to  the  effects  of  even  the  weaker  chemicals. 
But  under  the  most  favorable  conditions  their  effect  is  not  nearly  as 
rapid  as  that  of  boiling  water,  Mhieh  will  destroy  the  more  resistant 
spores  in  from  two  to  five  minutes,  while  the  effect  of  a  1  :  1000  solu- 
tion of  bichloride  of  mercury  upon  the  much  less  resistant  bacilli  of 
anthrax  or  upon  the  staphylococcus  pyogenes  is  not  assuredly  destructive 
in  fifteen  minutes  (Geppert). 

'  Wolfhiigel :  MUtheUmujen  aus  dem  Kais.  Gesundheilsamt,  1881. 


CLEANSING   OF  THE  SKTN  AND   OF  MUCOUS  SURFACES.      685 

It  \vas  pointed  out  before  that  the  unqualitiwl  application  of  the 
results  of  ('X[)erinicnt  to  the  conditions  of  actual  surgical  ]iractice  would 
lead  to  serious  error.  While  in  cx]K'rinient  a  small  (juantity  of  bacilli 
gained  by  pure  culture  and  soaked  into  a  single  thread  of  silk  is  exposed 
to  tiie  effect  of  a  large  volume  of  the  germicidal  solution,  in  surgical  j)rac- 
tice  enormous  naasses  of  various  microbes,  imbedded  in  solid  and  semi- 
solid tissues,  sloughs,  scabs,  blood,  fffices,  grease,  and  dirt,  are  encountered 
by  a  limited  quantity  of  the  germicide.  While  in  the  experiment  the 
germicide  will  penetrate,  reach,  and  bathe  every  singh'  individual  of  the 
micro-organisms,  in  practice — for  instance,  in  a  suppurating  wound — 
only  a  very  limited  ((uantity  of  the  vast  masses  of  microbial  matter  \\\\\ 
come  in  actual  contact  with  the  solution.  Finall}-,  where  under  ex- 
perimental conditions  the  chemical  action  of  the  germicide  is  unim- 
paired by  accidental  disturbance,  here,  in  the  wound,  most  of  the  active 
princi]de  of  the  solution  will  be  neutralized  by  contact  with  albu- 
minoid components  of  the  tissues  and  discharges.  Hence  it  follows 
tiiat  the  theoretical  results  of  experiment  as  to  the  value  of  this  or 
that  germicide  must  differ  materially  from  those  gained  in  actual 
practice. 

The  principal  substances  that  frustrate  the  usefulness  of  germicidal 
acpieous  solutions  are,  first,  a  coating  or  adiaLrfurc  offatfi/  matter  impen- 
etrable to  water ;  and,  secondly,  the  albumin  contained  in  human  tissues 
and  their  discharges,  which,  united  with  some  of  the  strongest  metallic 
germicides,  changes  them  to  inert  albuminates  and  annihilates  their  ger- 
micidal properties. 

In  estimating  the  practical  utility  of  the  various  methods  of  disin- 
fection two  questions  are  of  the  utmost  importance :  First,  How 
much  time  is  consumed  by  the  procetlure  to  be  effective?  and,  secondlj/, 
Will  not  the  objects  to  be  disinfected  be  damaged  by  the  jirocess  ?  Where 
the  process  must  lie  accomplished  in  a  few  minutes,  germicidal  solutions 
are  entirely  inadequate,  \vhile  boiling  is  perfectly  satisfactory.  Where 
metal  instruments  are  to  be  disinfected,  corrosive  sublimate,  for  instance, 
is  inadmissible,  but  in  the  disinfection  of  the  skin  of  patient  and  sur- 
geon boiling  water  would  not  be  proper  or  agreeable.  Thus  it  will  be 
seen  tiiat  the  external  eonditions  influencing  disinfection  are  variable, 
and  tiiat  under  changing  eonditions  a  variation  of  the  process  of  disin- 
fection must  take  place.  Often — in  fact,  as  a  rule — several  of  the  known 
methods  of  sterilization  have  to  be  combined,  their  application  being 
either  simultaneous  or  successive.  To  illustrate  this  we  may  mention 
that  the  patient's  skin,  for  instance,  is  first  macerated,  then  shaved, 
scrubbed,  freed  from  grease  by  ether,  and  finally  exposed  to  bichloride 
of  mercury  ;  or  the  instruments  are  first  soaked,  then  scrubbed,  polished, 
finally  boiled  in  sodn,  solution,  and  so  forth. 

m.  Cleansing  of  the  Skin  and  of  Mucous  Surfaces. 

The  surface  of  the  human  body  is  a  very  hotbed  for  the  ])ropagation 
of  a  great  variety  of  micro-organisms.  With  the  aid  of  a  little  methyl- 
ene blue  it  can  be  readily  shown  that  the  surface  of  the  skin,  even  of 
a  very  cleanly  person,  is  literally  swarming  with  fungi,  bacilli,  and  cocci. 
The  predominance  of  this  or  that  microbe  is  determined  by  the  habits, 


686      THE  TECHNIQUE  OF  ANTISEPTIC  AND  ASEPTIC  SURGERY. 

opciipatioii,  and  state  of  li(>altli  of  tlic  individual.'  Ilairv  jilacos,  as  the 
licad,  armpits,  etc.,  and  es))('cialiy  the  ininicdiatc  nfij>liijorliood  uf  the 
natural  apertures  of  the  body,  are  very  rieh  in  microbes,  which  become 
iiotahly  multiplied  whenever  even  a  slight  disturbance  of  the  normal 
stati!  of  health  of  any  portion  of  the  skin  occurs.  Sweating  or  a  slight 
catarrhal  or  eczematous  condition  favors  tlie  multij)lieation  of  their 
growth  to  an  incredible  extent,  which  will  be  still  more  rank  in  the 
jtresence  of  a  suppurating  wound,  sinus,  or  ulcer.  And,  as  we  never 
can  tell  whether  pathogenetic  microbes  are  present  or  not,  one  of  the 
most  indispensable  conditions  of  safe  surgery  is  the  scrupulous  cleansing 
of  the  skin  of  the  field  of  an  operation  and  of  the  hands  of  those  that 
are  to  come  in  contact  with  it.  The  surgeon's  hand,  having  often 
unavoidable  contact  with  unclean  surfaces  infected  with  pathological 
organisms,  is  a  most  connnon  carrier  of  infection. 

The  disinfection  of  the  hands  is  not  an  easy  or  rapid  process.  The 
slipshod  methods  of  cleansing  tlie  hands  practised  in  the  early  period  of 
the  antiseptic  era,  when  a  scrubbing  even  was  deemed  superfluous  and 
main  reliance  was  placed  on  the  efficacy  of  the  carbolic  lotion,  were 
found  to  be  entirely  inadecpiate.  Fiirbringer's  excellent  labors  have 
taught  us  that  here,  as  elsewhere,  the  action  of  the  chemical  disinfect- 
ants is  accessory  only,  the  chief  importance  belonging  to  the  prejiaratory 
mechanical  cleansing.  The  dry  and  crusted  masses  of  bacterial  dirt 
must  be  first  softened  by  the  use  of  a  strong  alkaline  soap  and  hot 
water;  the  coatings  of  grease  must  be  dissolved  by  the  application  of 
ether,  benzine,  or  alcohol ;  then  the  razor  and  scrubbing-brush  have  to 
sweep  away  the  masses  of  macerated  filth.  Only  after  the  large  bulk 
of  dirt  has  been  removed  by  these  means  will  the  application  of  a  ger- 
micidal lotion  be  of  any  use.  In  fact,  a  very  careful  and  thorough 
mechanical  cleansing  will  under  most  circumstances  render  the  use  of 
germicidal  lotions  supcrfuous. 

Simple  as  this  jH'ocess  of  cleansing  seems  to  be,  its  value  will  depend 
on  the  conscientious  thoroughness  with  whicli  it  is  applied,  which  thor- 
oughness again  presents  the  most  remarkable  personal  variations  in 
various  medical  men.  While  with  some  few  a  sublimate  lotion  is  a  real 
superfluity,  the  cleansing  processes  of  others  are  so  shallow — in  fact,  a 
mere  sliam — that  in  their  ease  the  al)andonnient  of  chemicals  would 
mean  all  forms  of  surgical  disaster.  And  as  long  as  the  meaning  of 
the  canons  of  cleanliness  will  have  to  depend  on  the  individual  inter- 
jiretation  of  the  practitioner,  the  use  of  chemicals  cannot  be  excluded 
from  sui'gical  practice. 

The  difference  between  what  is  termed  asepsis  and  antisepsis  is  strik- 
ingly illustrated  by  the  preceding  remarks.  Where  mechanical  and 
caloric  measures  are  applicable  and  sufficient  to  the  attainment  of  a 
state  of  freedom  from  micro-organisms,  there  we  have  asepticism.  Where 
this  is  not  the  case — that  is,  -where,  either  on  account  of  the  inherent 
condition  of  the  surfaces  to  be  dealt  with,  or  because  of  the  low  order 
of  the  conception  of  purity  of  the  medical  attendant,  heat  and  scrubbing 
cannot  or  are  not  used  to  their  full  extent — chemicals  must  be  accepted 
as  a  makeshift,  and  the  process  is  termed  antisejisis. 

'Fiirbringer:  "  Untersuchungen  iiber  die  Desinfection  der  Hiinde,"  Deutsche  med. 
Woehenschrift,  1888,  No.  48. 


CLEANSING   OF  THE  SKIN  AND  OF  MUCOUS  SURFACES.     687 

Among  the  several  methods  of  disinfecting  the  surffcon'.i  hands,  this 
one  can  be  conscientiously  recommended  : 

1.  Rub  a  sufficient  quantity  of  green  or  soft  soap  into  the  hands  and 
n{)on  the  bared  arms  ;  then  scrub  them  in  hot  water  with  a  stitf  brusli 
for  one  minute,  paying  special  attention  to  the  nails  and  the  subungual 
spaces. 

2.  After  scrubbing,  the  spaces  under  the  nails  must  be  carefully  freed 
from  all  loose  matter  by  the  use  of  a  nail-cleaner. 

3.  The  iiands  are  now  immersed  for  one  minute  in  strong  alcohol  (80 
per  cent.). 

4.  Finally,  they  are  immersed  in  a  1  :100()  solution  of  bichloride  of 
mercury  for  one  minute,  during  which  tiiis  solution  is  to  be  well  rubbed 
into  all  folds  and  creases  by  the  aid  of  a  brush. 

There  are  other  raetiiods  just  as  reliable  as  this  one,  notably  that  in 
wliich  permanganate  of  potash  is  used  ;  but  the  necessity  of  employing 
oxalic  acid  for  the  decoloration  of  tiie  epidermis,  deeply  stained  by  the 
manganate  salt,  is  a  great  drawback  to  its  use. 

Similar  principles  jirevail  in  cleansinff  the  skin  of  the  patient,  with 
some  important  modifications  rendered  necessary  by  unusually  adherent 
deposits  of  dirt  : 

1.  The  skin  is  shaved,  not  only  in  the  armpits,  on  the  head,  flice, 
pubic  and  anal  regions,  but  wherever  an  operation  is  to  be  performed. 

2.  Whenever  possible  a  general  bath  should  precede  the  consequent 
steps. 

3.  Where,  as  on  the  hands  of  laboring-men,  or  on  the  feet  of  people 
accustomed  to  go  barefoot,  or  in  persons  of  unusual  uncleanliness,  tiie 
deposit  of  dirty  e])iderniis  is  very  thick  and  massive,  the  parts  should 
be  envelo])ed  for  several  hours  in  a  wet  jiack  of  soajj-water,  by  which 
the  epidermal  coating  will  Ije  sufficiently  macerated  to  yield  to  tiie  scruli- 
bing-brush. 

4.  Friction  with  water,  soap  and  brush,  and  ether  must  then  be 
applied  until  all  crumbs  and  flakes  of  loose  epidermis  are  removed  and 
the  skin  becomes  clean  and  glossy. 

5.  Finally,  the  skin  is  rubbed  off  with  a  1  :1000  solution  of  Ijichlo- 
ride  of  mercury. 

We  cannot  leave  this  subject  without  devoting  a  few  remarks  to  the 
tools  and  substances  used  for  cleansing,  notably  to  soap  and  brushes. 

Eiselsberg '  ascertained  that  all  fiirnis  of  soap  manufactured  by  a 
process  of  boiling  are,  as  a  rule,  germ-free ;  on  tlie  other  hand,  soap 
produced  by  a  cold  process  of  blending  tiie  alkali  with  fats  is  unreliable 
and  sliould  be  shunned. 

As  to  inrushes,  it  will  need  no  special  jiroof — though  this  lias  been 
abundantly  furnished. by  Schimmclbusch " — tiiat  after  having  been  used  in 
contact  with  filthy  surfaces,  with  blood,  pus,  and  faeces,  they  must  become 
ciiarged  with  enormous  masses  of  noxious  germs.  The  destruction  of  tiiese 
germs  by  diemical  agents  alone  is  uncertain  and  reipiires  a  verv  long  time. 
On  tlie  r)tlier  iiand,  a  short  boiling  of  five  minutes  in  jilain  water  or 
in  water  ciiarged  with  1  per  cent,  of  common  soda  will  surely  render 
any  brush  germ-free.     The  cheap  brushes  made  of  vegetable  fibre  should 

'  "  ITeber  den  Keimgehalt  von  Soilen,  etc.,"  Wiener  med.  Woclienscliri/t,  18S7,  No.  29. 
2  Archiv  fib-  CKiruryic,  1891,  pp.  1(13-170. 


(588     THE  TECHXIQUE  OF  ANTISEPTIC  AND  ASEPTIC  SURGERY. 

receive  the  preference,  because  hnislies  made  of  bristles  are  claniap;e(l  by 
boiliiifi'.  The  brushes  used  in  an  operating-room  should  be  boiled  every 
day  with  the  instruments.  Those  that  were  used  in  contact  with  sej)tic 
material  should  either  be  set  aside  or  nuist  be  immediately  boiled  bctbre 
being  used  again.  After  boiling  in  soda  solution  the  brushes  should  be 
kept  immersed  in  a  1:1000  solution  of  sublimate.  The  brushes  eni- 
jiloyed  on  the  washstantls  of  liospital  wards  or  bed-rooms  also  need  fre- 
quent boiling. 

The  dcaimng  of  mucous  surfaces  with  a  view  to  their  disinfection  i.s 
a  much  more  difficult  matter  than  that  of  the  outer  skin,  and  here  the 
use  of  chemical  germicides  is  strictly  limited  by  the  dangers  of  absorp- 
tion and  poisoning.  Hence  tlie  jirocesses  of  wiping,  flushing,  and  the 
mechanical  remoral  of  fa;ces  or  mucus,  together  with  measures  directed 
against  the  escape  fif  tieces,  bile,  or  urine  during  an  operation,  as  by  i)hig- 
ging  or  temporary  ligature,  will  deserve  the  preference  over  germicidal 
lotions. 

IV.  The  Sterilization   of  Instruments. 

For  preparing  instruments  for  an  operation  their  mechanical  cleansing 
from  lilood,  pus,  shreds  of  fibrin  and  tissues,  or  caseous  or  greasy  material 
by  soa})-water  and  a  brush  must  be  the  initiatory  step.  Though  by  these 
means  the  bulk  of  the  noxious  substances  clinging  to  the  irregular  sur- 
faces of  the  instruments  will  certainly  be  dislodged,  yet  a  sufficient 
quantity  of  microbes  will  still  adhere  to  them  to  menace  the  welfare  of 
the  wound.'  Hence  to  render  the  instruments  perfectly  germ-free  some- 
thing more  will  have  to  be  done. 

What  is  desired  is  a  mcthfid  that  is  adequate  and  practical — that  is, 
not  consuming  too  much  time  or  injurious  to  the  instrumeuts. 

To  eflect  an  adequate  sterilization  of  metal  instruments  hot  air,  steam, 
or  boiling  in  water  can  be  considered.  The  first  is  impractical,  as  it  de- 
mands special  and  bulky  apparatus  and  consumes  considerable  time.^ 
The  second  is  objectionable,  because  it  rusts  the  instruments.  The  third 
— that  is,  boiling — is  simple,  rapid,  and  adequate.  Its  objectionable 
feature — that  is,  the  rusting  of  the  instruments — has  been  admirably 
eliminated  by  Davidsohn's  and  Schimmelbusch's  exjjedient  of  charging 
the  water  with  cooking  soda  in  tlie  jiroportion  of  1  per  cent,  of  its  quan- 
tity. The  presence  of  the  soda  will  not  only  prevent  rusting,  but  also 
will  render  the  disinfection  more  tliorougli  and  rapid.^  To  test  this  very 
question  Schimmelbusch  ^  has  impregnated  strands  of  silken  and  woollen 
thread  with  pus  and  pure  cultures  of  staphylococcus  pyogenes  aureus,  of 
the  bacillus  pyocyaneus,  and  with  anthrax  spores,  after  which  they  were 
immersed  for  varying  lengths  of  time  in  a  boiling  soda  solution.  It  was 
found  that,  ^vithout  exception,  the  micro-organisms  contained  in  pus,  as 
well  as  the  staphylococcus  and  bacillus  pyocj'aneus,  were  destroyed  in 
from  two  to  three  seconds,  whereas  the  spores  of  anthrax  which  had  re- 
sisted the  effect  of  steam  heated  to  100°  Celsius  for  twelve  minutes  were 

•  Schimmelbusch  :  Berliner  Uin.  Wochenschrifi,  1888,  No.  35. 

'  Poupinel :  "  Sterilisation  par  la  Chaleur,"  Revue  de  Cliirwgie,  1888. 
3  "  Wie  soil  der  arzt  seine  instrumente  desinficiren,"  Berliner  kliyi.  Woctiemchrift,  1888, 
No.  35. 

*  Aideiiung  zur  asepl.  Wundbehandlung,  p.  65. 


THE  STEEILIZATIOy  OF  INSTRU3IENTS. 


689 


invariably  Ivillcd  l)y  the  Ijoiling-  soda  sDlution  within  two  minutes.  Ac- 
cordingly, it  may  be  asserted  that  a  brief  submersion,  extending  over  a 
few  seconds,  in  a  boiling  soda  solution  Mould  under  ordinary  circum- 
stances sterilize  a  surgical  instrument,  but  that  a  boiling  of  five  minutes 
will  certainly  and  relialily  jinuluce  this  eifect  un<ler  any  and  all  circum- 
stances. 

The  eminent  disinfecting  ([ualities  of  the  soda  solution  were  carefully 
tested  by  ]jchring,'  who  found  tluit  by  the  ordinary  processes  of  the  laun- 
dry, during  which  a  temperature  of  80-85°  Celsius  is  rarely  exceeded, 
the  spores  of  anthrax  were  very  often  destroyed  in  four,  and  certainly 
\vithin  eight  or  ten,  minutes. 

Aside  from  its  eminent  l)actericidal  power,  this  method  commends 
itself  to  the  practitioner  by  its  general  applical)ility.  Water,  soda,  a  pan 
or  pot,  and  tire  to  heat  them,  will  be  found  everywhere,  and  under  all 
circiunstanccs  aTid  almost  anywhere  can  the  surgeon  secure  a  reproacliless 
state  of  asepticism  for  his  instruments.  For  practical  purposes  it  may 
be  said,  then,  that  one  tablvxpoonful  of  flic  common  irasliinr/  aoda  to  a  quart 
of  irate r,  boiled  for  fire  miinifex  iritli  (lie  instnimentx,  /.v  fhe  best  means  of 
(lislnfectine/  f/tein. 

For  clinical  purposes,  when  the  same  set  of  instruments  has  to  be  used 
in  two  or  three  separate  and  subsequent  operations,  Schimmelbusch  has 

Flu.  173. 


Schimmclliuscli's  instrument-boiler. 


devised  a  very  practical  boiler  heated  by  gas-jets  (Fig.  173).  The  instru- 
ments are  placed  on  a  wire  tray  with  suitable  handles,  which  tray  is 
immersed  in  the  solution  for  five  minutes,  after  whicii  the  in.striiments 

'  ZeilschriJ'l J'iir  Hyyiene,  1890. 
Vol.  1.— 44 


690     TIIK  TECHNIQUE  OF  ANTISEPTIC  AND  ASEPTIC  SURGERY. 

can  bo  At  once  placed  in  the  tray  which  is  to  hohl  thcni  during  tlie 
operation.  For  various  )-eason.s  it  is  i^ood  to  keej)  them  there  in  a  batli 
oi'  plain  hoik'd  water,  or,  better  still,  in  a  cold  so(hi  solution,  ijuantities 
of  which  can  be  kept  on  hand. 

It  is  necessary  to  add  that  old-t'asliioned  instruments,  provided  with 
wooden  or  ivory  handles,  Avill  very  soon  be  ruined  by  tliese  procedures ; 
hence  it  is  desirable  that  such  only  should  be  used  as  arc  entirely  com- 
posed of  metal  parts.  The  nickel-plating  of  instruments  can  be  entirely 
<lispensed  with  as  unnecessary.  Aluminum  is  ])ronij)tly  attacked  by 
alkaline  solutions,  and  is  not  to  be  subjeeti'd  to  tiiis  form  of  sterilization. 

The  receptacles,  cases,  and  safes  for  tlie  keejiing  of  instruments  siiould 
have  tight  doors.  They  arc  best  constructed  of  iron  with  glass  panels 
and  shelves,  and  should  be  kept  closed  against  dust  all  the  time. 

The  old-flisiiioned  silk-lined  ])ocket-instrument  case  of  leather  is  out 
of  date,  and  should  be  supplanted  by  a  washal)le  canvas  case,  which  ought 
to  be  cleansed  l)y  boiling  as  often  as  practicable. 

Afiplrat'niy  and  Injecting  Syringes. — Tiie  disinfection  of  syringes  and 
hollow  needles  used  for  aspiration  and  for  the  injection  of  liquids  into 
human  tissues  requires  special  attention.  The  sources  of  infection  may 
l)e  here  the  skin  of  tlie  patient,  the  injected  fluid,  and  the  syringe.  The 
careful  cleansing  of  the  skin  should  precede  every  puncture,  whether  for 
asj)iration  or  injection,  as  a  matter  of  course.  As  to  the  fluids  to  be 
injected,  this  may  be  said,  that  Schinnuelbusch '  examined  a  number 
of  standard  solutions,  proi'ured  either  from  leading  drug-stores  or  from 
the  Avards  of  the  Berlin  surgical  clinic,  and  foimd  tiiat  they  all  contained, 
as  a  rule,  large  quantities  of  micro-organisms.  Solutions  of  1  per  cent,  of 
j)ilocarpine  muriate,  for  instance,  were  swarming  with  bacteria  ;  a  solu- 
tion of  ergotine  contained  10, (MM)  germs  to  the  cubic  centimetre  ;  and  tiie 
standard  solution  of  morphine  rarely  contained  less  than  from  200  to  300 
germs  per  c.c.  Much  purer  were  found  iodoformized  glycerin  (10  per 
cent.),  camphorated  oil,  and  the  watery  sf)lutions  of  hydroeldorate  of  apo- 
morphia,  of  bisulphatc  of  eliinine,  of  antipyrine,  and  of  the  mercurial  salts. 

Ferrari'  studied  the  behavior  of  various  noxious  miero-t)rganisms 
introduced  into  substances  used  for  hypodermic  injections,  and  found 
that  staphvlococcus  pyogenes  aureus  was  instantly  killed  by  ether,  tinc- 
ture of  musk,  and  concentrated  solutions  of  chiniue — that  it  still  lived 
after  two  hours  in  a  10  per  cent,  solution  of  cocaine.  The  same 
organism  died  in  a  2  per  cent,  solution  of  morphia  only  after  twenty- 
four  hours,  in  glycerin  after  six  days.  In  distilled  water,  however,  in  a  1 
]>er  cent,  solution  of  atropia,  and  in  ordinary  morphine  solutions  the  micro- 
oriranisms  not  only  remained  living  fir  weeks  and  months,  but  increased 
and  multiplied  to  an  enormous  extent. 

It  stands  to  reason  that  certain  strongly  germicidal  substances,  as 
ether,  alcohol,  tincture  of  iodine,  solutions  of  carbolic  acid  and  of 
bichloride  of  mercury,  need  no  s])ecial  prejiaration  ;  but  solutions  of 
atropine,  morphia,  eticaine,  and  pilocarpine,  whieii  are  especially  prone 
to  microbial  invasion,  must  receive  more  than  ordinary  attention.  Of 
these,  especially  cocaine  is  used  frequently  in  small  o])erations,  and  when 

'  Schimmelbusch  and  Holil:  Ankihinfi  zur  asept.  Wnndhehtnirllmici,  p.  120. 
'' "  Ueber  das  Verhalten  der  Micro-organismen  in  den  subcutan.  einziisjiritzeiiden  Fliis- 
sigkeiten,"  Ccnlralblatl  Jiir  Backrioloyie,  vol.  iv.  p.  744. 


DRESSINGS.  691 

impiiro  may  lead  to  serious  disturbances  of  tlie  liealing  of  a  wound.  A 
brief  ])reliniinary  boiling  in  a  teaspoon  over  a  lamp-  or  gas-flame  will  be 
I'ound  a  rcuily  means  of  destroying  germs  contained  in  any  of  these  solu- 
tions. Where  larger  (juantities  are  to  be  preserved,  an  addition  of  a  few 
<lr(>ps  of  concentrated  carbolic  acid  to,  say,  an  ounce  of  solution  will  be 
fountl  very  useful.  As  to  the  syringes  themselves,  it  must  be  said  that 
they  are,  as  a  rule,  easily  infected  and  very  hard  to  keep  clean,  especially 
those  made  of  hard  rubber  and  having  leather  washers.  Koch's  balloon 
.syringe  is  easilv  cleansed  and  reliable,  but  not  useful  for  the  purposes  of 
tile  .surgeon,  and  is  far  surpassed  by  tlie  old-fashioned  barrel-syringe. 
Overlach  has  constructed  a  barrel-syringe  whicii  has  a  compressible 
rubber  ])ist(in,  glass  barrel,  and  metal  mountings.  This  instrument  can 
be  Ixiiled  without  injury  and  can  be  easily  made  aseptic. 

To  study  the  value  of  the  various  ordinary  methods  of  cleansing 
hypodermic  svringes  Schimmclbusch '  first  thorf)Ughly  sterilized  an 
Overlacii  syringe,  then  tilled  it  with  pus,  emptied  it,  then  repeatedly 
tilled  it  with  and  emptied  it  of  distilled  water.  Tile  number  of  cocci 
was  thus  materially  diminished,  but  after  ten  fillings  and  emptyings  the 
ejected  water  still  contained  thousands  of  germs.  A  3  per  cent,  solution 
of  carbolic  acid,  1  :  2000  of  corrosive  sublimate,  and  absolute  alcohol 
gave  somewhat  better  results,  but  the  best  of  all  was  squirting  hoUing 
water  through  tiie  syringe.  After  the  instrument  was  thus  filled  and 
enij)tied  five  times  it  was  found  absdluteiy  sterile. 

Tlie  iiolldw  needles  used  for  injection  and  aspiration  are  liest  disin- 
fected by  boiling  in  soda  .solution.  Drawing  them  through  an  alcohol 
flame  will  certainly  sterilize  them,  but  also  will  destroy  their  temper, 
as  they  are  made  of  steel.  Platinum-iridium  canulas  will  withstand  red 
heat  excellently,  but  are  expensive. 

V.  Dressings. 

In  oiiserving  the  course  of  one  of  the  many  small  wounds  accident- 
ally inflicted  upon  ourselves  with  a  clean  instrument,  of  a  wound  left 
entirely  to  itself  and  not  interfered  with  in  any  way,  we  shall  get  the 
model  of  repair  which  is  the  i<leal  aim  of  the  surgeon.  After  cessation 
of  tiie  iieniorrhage  tlie  li])s  of  the  wound  ln'come  agglutinated  by  l)lood- 
dot,  whicli  gradually  desiccates  and  occludes  the  wound  in  the  manner 
of  a  hermetic  seal.  After  the  first  smarting  has  passed  away  there  will 
be  no  jiain,  no  redness,  no  heat  as  long  as  the  ]iarts  are  left  undisturbed, 
and  after  the  lapse  of  six  or  seven  days  the  dry  crusted  blood  will  peel 
off'  and  the  fresh  sound  cicatrix  will  come  to  view.  AVliere  the  wound 
is  somewhat  more  extensive,  yet  not  large  enough  to  rei|uire  suture,  the 
drying  of  the  blood-clot  is  preceded  by  .some  oozing  of  blood-serum  out 
of  tiie  clot.  The  watery  part  of  this  serum  will  gradually  evaporate,  and 
its  solid  constituents  will  ultimately  form  into  a  dry  crust,  forming  a  sort 
of  ])roteetive  seal  both  to  the  edges  of  the  wound  and  to  the  clot  filling  it. 
In  this  case  the  course  of  liealing  will  lie  identical  witii  that  just  depicted, 
always  ]irovidcd,  however,  that  the  protective  crust  is  not  interfered 
Avith  and  that  no  septic  matter  enters  the  wound  at  any  time. 

Using  this  experience  as  a  paradigm,  the  surgeon  may  safely  imitate 

'  Antfitung,  etc.,  p.  124. 


692     THE  TECHNIQUE  OF  ANTISEPTIC  AND  ASEPTIC  SURGERY. 

the  process  in  the  treatment  of  comparatively  small  and  simple  wounds, 
such,  for  instance,  as  occur  in  dclii;atioii  of  artei'ies  in  continuity,  in 
herniotomy,  or  in  the  extirpation  of  small  tumors.  T(j  ensure  the  stabil- 
ity of  the  relations  of  the  several  parts  of  a  small  wound  we  apply  an 
appropriate  number  of  catgut  stitt^hes ;  then  spread  over  the  line  of 
union  a  narrow  strip  of  gauze,  and  saturate  this  with  flexible  collodion, 
which  will  seal  up  hermetically  the  wound  and  its  inHn<'diate  cdufincs. 
If  there  be  no  persistent  and  copious  oozing,  the  wound  will  heal  under 
this  artiiicial  scab  without  trouble.  In  about  ten  davs  the  collodion  will 
become  loose,  and,  it  being  raised,  the  stitches  will  be  found  absorbed  and 
the  wound  firmly  healed. 

But  where  the  wound  is  extensive,  and  where  the  oozings  are  too 
copious  to  be  promptly  desiccated  by  evaporation,  another  method  must 
be  pursued  to  secure  rest  to  the  wound  and  to  jirevent  infection  from 
without.  Ah.wrhenf  drcssinr/.s  take  their  jilace  here,  and  will  now  re- 
quire our  consideration. 

To  answer  modern  requirements  dressing  materials  must  possess  the 
following  qualities : 

1.  They  must  be  absorbent  to  a  high  degree; 

2.  They  nuist  be  aseptic  ; 

3.  They  nnist  possess  the  quality  of  remaining  aseptic  even  if  satu- 
rated with  tliseharges. 

Of  the  various  materials  used  for  dressings,  gauze  or  cheese-cloth,  first 
selected  by  Lister  himself,  has  remained  to  this  day  the  most  highly 
prized  and  most  universally  used.  Of  others  we  may  mention  fuller'.s 
earth,  sawdust,  ashes,  sand,  peat,  oakum,  jute,  tow,  asbestos,  spun  glass, 
wood-wool,  cotton  batting,  lilotting-papcr,  and  moss, — among  which, 
however,  only  the  last  three  and  sawdust  have  a  practical  utility.  Saw- 
dust, cotton  batting,  and  absorbent  cotton,  finally  blotting-paper,  may 
furnish  very  good  material  for  extemporized  dressings  in  emergencies. 
Sterilized  moss  (various  species  of  sphagnum),  being  highly  absorbent 
and  very  cheap,  is,  on  account  of  the  great  saving  that  is  involved  by  its 
use  as  against  the  more  costly  gauze,  very  important  in  hosjiital  economy. 

As  to  energy  of  absorption  both  as  to  quantity  and  raj)idity,  absorb- 
ent gauze  and  moss  occupy  the  highest  point.  Excellent  absorbent 
gauze  can  be  procured  now  everywhere  in  suitable  quantities  and  for 
little  money.  Where  it  cannot  be  bought  the  surgeon  may  easily  render 
common  unbleached  cheese-cloth  absorbent  by  boiling  it  for  half  an  hour 
in  a  5  per  cent,  solution  of  soda  or  in  ]>otash  lye,  liy  which  process  sa- 
ponification of  the  oily  matter  contained  in  the  cotton  fibre  is  effected. 
The  cheese-cloth  is  rinsed  in  cold  water,  and  after  drying  possesses  con- 
siderable though  not  as  high  absorbent  power  as  the  bleached  manufac- 
tured article  of  trade. 

The  second  and  most  indispensable  condition  which  mu.st  be  fulfilled 
before  any  dressing  material  is  fit  for  surgical  use  is  a  complete  freedom 
from  pfdhof/cnetie  (/ermf;. 

Our  present  knowledge  of  the  ])art  ])layed  by  noxious  germs  in  the 
causation  of  wound  diseases  has  fully  confirmed  the  epigrammatic  saying 
of  Volkmann,  that  the  human  organism  is  not  a  test-tube  filled  with 
gelatin  or  agar-agar.  We  know  that  not  every  contact  with  noxious 
germs  must  inevitably  lead  to  infection  ;  but,  on  the  other  hand,  we  also 


DRESSINGS.  693 

know  how  promptly  the  streptococcus  of"  erysipelas,  for  instance,  will 
enter  the  lymphatics  through  a  superficial  denudation.  Hence  measures 
at  rendering  our  dressings  germ-free  must  be  considered  important 
indeed. 

Freedom  from  germs  of  the  gauze  sold  in  neat  tin  boxes  by  various 
wholesale  drug  firms  is,  though  expressly  guaranteed,  very  unrelial)le. 
^\^nd  if  we  consider  the  ordinary  methods  of  mamifa<^ture  and  trade,  we 
shall  not  expect  too  much  from  that  source.  Fortunately,  we  have  at 
our  connnand  ready  and  prompt  means  for  rendering  dressing  materials 
aseptic. 

Of  these,  impregnation  of  the  fabric  used  for  dressings  icith  chemicals 
must  be  first  mentioned.  Lister's  first  efi'orts  were  made  in  this  direction 
when  he  saturated  gauze  with  a  resinous  mixture  chargctl  witJi  carljolic 
acid.  Later,  corrosive  sublimate  displaced  carbolic  acid,  but  most  of 
the  objections  justly  raised  against  the  former  also  applied  to  the  latter. 
Aside  from  the  fact  that  the  ordinary  processes  of  imj)regnation  gave 
verv  unequal  results,  tlic  objection  that  carbolic  acid  eva])(>rated  from  the 
dressings  was  etpialled  by  the  fact  that  the  mercurial  salt  was  also  evan- 
escent, and,  moreover,  was  liable  to  decomposition.  Furthermore,  the 
serious  drawback  became  only  too  often  evident  that  both  of  these 
irritated  the  skin,  protlueing  very  acrid  eczemata,  and  often  led  to  raoi"e 
or  less  dangerous  states  of  intoxication  due  to  direct  absor])tion  by  the 
blood.  The  simple  fact  that  impregnation  or  sterilization  was  not  the 
last,  but  the  first,  step  in  the  preparation  of  the  dressings,  and  that  it 
was  followed  by  more  or  less  unavoidable  handling  by  attendants  and 
nurses  in  the  course  of  drying,  foldiug,  cutting,  and  storing  of  the 
gauze,  made  this  plan  extremely  unrelialile. 

Most  of  these  objections  disappear  when  we  employ  heat  for  steril- 
izing dressings.  Here  all  the  cutting  and  folding  can  be  done  in  advance  ; 
the  prepared  dressings  are  sterilized  and  left  until  needed  in  the  wrap  or 
receptacle  in  which  tiiey  were  subjected  to  the  influence  of  heat.  Should, 
however,  circumstances  compel  the  practitioner  to  rely  upon  chemical 
sterilization,  it  is  best  to  impregnate  the  dressings  immediately  preceding 
their  use.  Sublimate  deserves  the  preference  over  cai'bolic  acid,  and  the 
strength  of  the  solution  should  be  1  :  2000. 

In  hospital  practice,  and  where  the  conveniences  can  be  easily  pro- 
cured, sterilizing  by  sleaui  has  nuich  to  commend  it,  but  in  an  emergency 
am/  fabric  to  be  sterilized  extempore  can  be  made  reliably  aseptic  by 
boiling  for  fifteen  minutes  in  a  1^  per  cent,  solution  of  mishing  soda 
in  water. 

For  steam  sterilization  excellent  aud  sim])le  apparatuses  have  been 
devised,  their  prineij)le  being  mainly  derived  from  Koch's  sterilizer.  In 
hospitals  an  existing  steam-])lant  can  be  conveniently  connected  with  the 
sterilizer,  in  which  all  the  dressing  materials,  gowns,  roller  bandages, 
aprons,  etc.  needed  for  the  day  may  receive  their  purification  just  before 
use. 

The  ])rinciples  upon  which  all  useful  sterilizers  of  large  size  must  be 
constructed  are  these  : 

1.  Tiie  objects  to  be  disinfected  must  receive  a  j)reparatory  warming 
within  the  apparatus  to  prevent  precipitation  of  steam. 


I)il4     THE  TECHNIQUE  OF  ANTISEPTIC  AND  ASEPTIC  SURGERY. 

2.  Tlic  steani   iiiiist   enter  the  iippiiratus  i'roiii  aljovc   and  not  from 
below. 

3.  The  steam  nmst  liave  a  certain  degree  of  tension. 

4.  The  dressings  must  be  dry  when  tiiey  leave  the  apparatus. 
Preparatory  warming  is  inij)ortant,  because  the  contac-t  of  hot  steam 

with  cold  dressings  will  produce  condensation,  and  the  dressings  will 
become  damp  or  even  wet.  This  pre])aratory  warming  is  secured  by  a 
double  jacket  to  the  apparatus.  Steam  circniatcs  through  this  and  warms 
tlu'  contents  of  the  central  s])ace  before  this  is  entered  by  steam.  Gruber, 
Frosch,  and  Clarenbach  have  demonstrated  that  when  steam  enters  the 
disinfecting  space  of  an  apparatus  from  below  the  atmospheric  air  is  not 
driven  out  at  once  and  as  uniformly  as  ^^■hen  the  steam  enters  from 
above.  The  cause  of  this  is  the  fact  that  air,  being  heavier  than  hot 
steam,  will  naturallv  tend  to  return  to  the  bottom  of  the  a])paratus  in 
eddies,  much  of  the  steam  escaping  directly  above,  without  uiiit()rmly 
jjcrmeating  the  entire  enclosure.  When  steam  enters  from  above  the  air 
is  displaced  gradually,  uniformly,  and  steadily.  Teuscher's  observations, 
made  on  an  ajiparatus  that  admitted  steam  either  from  above  or  from 
below,  showed  tiiat,  steam  being  admitted  from  below,  tlie  recjuisite  tem- 
perature of  100°  Celsius  was  reached  in  twenty -two  minutes  and  twenty 
seconds,  whereas  if  the  steam  entered  from  above  the  same  temperature 
was  registered  after  seventeen  minutes. 

A  slightly  increased  tension,  which  is  gained  by  resistance  offered  to 
the  escape  of  the  steam  through  the  apparatus  itself,  is  useful,  because 

Fig.  175. 


-2_ 


■»  J 


t   ) 


pr 


(Front  view. I  (Sectional  view.) 

Schimnielbusch's  combined  sterilizer. 


it  guarantees  a  ra])id  ])crmeation  of  the  dressings  and  facilitates  their  sub- 
sequent spontaneous  drying,  which  will  l)e  all  the  prom])ter  as  the  pre- 
liminary warming  was  thorough. 

Schimraelbusch  '  and  Willy  Meyer  -  have  described  very  useful  small 
sterilizers,  for  the  use  of  the  surgeon  in  jirivate  practice,  that  have  stood 

'  Anleittrng,  etc.,  p.  84.  =  3Ied.  Record,  M.irch  3,  1894,  p.  285. 


DRESSINGS. 


695 


Fig.  176. 


the  test  of  actual  use  and  can  be  well  reci^nnniendcd.  Tiiey  permit  of 
a  combined  sterilizatiou  both  of  instruments  by  boiling  in  soda  solu- 
tion and  of  dressings  in  the  escaping  steam.  For 
hospital  use  Lautenschlager's  apparatus  Mill 
answer  admirably.  Schinnnell)usch's  capsules 
or  boxes,  proviiled  with  a  number  of  lateral 
holes  which  can  be  opened  or  closed  by  a  single 
sliding  arrangement,  have  been  found  extremely 
useful.  The  number  of  these  boxes  to  be  pro- 
vided de])ends  upon  the  amount  of  operative 


work  rcgularlv  done  in  a  given  institution. 


All 


Box  fur  dressing. 


the  dressings,  bandages,  gowns,  etc.  pertaining 
to  one  operation  are  placed  in  one  of  these 
boxes,  which  is  then  closed.  The  lateral  aper- 
tures are  thrown  open  and  the  box  is  put  in  tiie  sterilizer.  Having 
been  exposed  to  the  action  of  steam  for  thirty  minutes,  the  box  is  removed 
from  the  sterilizer,  tlie  lateral  holes  are  closed,  and  now  the  box  with 
its  contents  can  be  left  hermetically  sealed  until  the  moment  wiien  the 
dressings  are  actually  needed.  A  large  apparatus  will  hold  six  or  eight 
such  boxes,  and,  the  handling  of  the  dressings  having  all  been  done  before 
sterilizing,  these  will  come  to  the  wound  in  an  ideally  clean  condition. 

It  was  pointed  out  before,  that,  to  be  admissible,  a  dressing  must 
have  the  (piality  of  preventing  the  undue  multiplication  of  pathogenetic 
germs  in  the  discharges  by  which  it  becomes  permeated,  or  even  have  a 
direct  germicidal  influence  upon  those  germs  that  are  natui-ally  contained 
in  the  secretions.  Formerly  we  endeavored  to  accomplish  this  by  im- 
pregnation with  chemical  agents,  as,  for  instance,  carbolic  acid  or  cor- 
rosive sublimate.     But  the  defects  of  this  plan,  developed  in  the  course 

Fig.  177. 


Willy  Meyer's  portable  sterilizer. 


of  actual  practice,  and  mentioned  before,  are  so  serious  and  important 
that  the  necessity  of  an  inipni\'ement  was  keenly  felt  everywhere.  j\.s 
an  expression  of  this  must  be  taken  the  long  series  of  trials  witii  various 
chemicals,  whici),  iiowever,  but  strengtiiened  tiie  distrust  felt  toward  them. 
Only  since  Neuber  demonstrated  that  the  most  energetic  parasiticide  is 


cm     THE  TECHNIQUE  OF  ANTISEPTIC  AND  ASEPTIC  SURGERY. 


(Iryneas — that  by  encouragino;  a  rapid  evaporation  of  the  fluid  j)art  of 
the  discharges  ountained  in  a  dressing;  we  shall  check  much  luore  effec- 
tively the  proliferation  of  microbes  tlian  by  means  of  chemical  agents 


Flci.  178. 


Fig.  179. 


External  and  sectional  views  of  Lautenschliiger's  sterilizer. 


added  to  the  gauze, — only  since  then  Mere  we  able  to  relinquish  the  use 
of  unreliable,  irritating,  and  poisonous  chemicals.     Xeuber  demonstrated 

in  actual  practice  that  a  dressing,  however  soaked 
Fig.  180.  full  with  the  first  discharges  of  a  fresh  wound, 

remained  perfectly  sweet  for  an  indefinite  time 


Fig.  181. 


LiLutunsfhlujicr's  sturilizur:  StliimiiiLlliiiM.li's  dressing-box. 

if  by  rapid  evaporation  a  drying  up  of  the  discharges  was  brought 
about.     The  crusted  discharges  thus  formed  a  sort  of  aseptic  seal,  like 


DRESSINGS.  G!I7 

the  dried  blood-clot  in  the  small  wound  we  have  used  as  an  illustration 
at  the  beginning-  of  this  paper.  Practically,  the  wound  by  this  process 
was  converted  into  a  subcutaneous  injury. 

But  all  this  refers  only  to  fresh  wounds,  the  discharges  of  which  are 
serous,  thin,  and  not  septic.  Where  we  have  to  deal  with  suppiu-ating 
wounds,  with  secretions  that  are  thick,  viscid,  and  often  contain  consid- 
erable masses  of  deeomjiosing  detritus  and  slough,  rapid  evaporation  and 
inspissation  become  a  drawback.  First,  the  dressings  cannot  readily 
absorb  the  discharges,  which  remain  pent  up,  as  it  were,  altout  the 
orifice  of  the  wound.  As  soon  as  evaporation  leads  to  crusting,  these 
discharges  become  sealed,  and  retention  with  all  its  harmful  consequences 
is  the  direct  effect.  Here,  then,  woLs-t  dressingf!,  the  jH'evention  of  evap- 
oration by  the  use  of  impermeable  coverings,  and  frequent  changes  of 
dressing  accompanied  by  a  thorough  cleansing  of  the  wound,  represent 
the  order  to  be  followed. 

Wherever,  for  various  reasons,  it  is  needed  to  ])ack  or  tampon  a 
wound,  moist  treatment  is  preferable  to  the  dr}-,  and  here  imj)regna- 
tion  of  the  packings  ^vith  Iodoform  is  highly  convenient.  The  inhib- 
itory action  of  iodoform  upon  the  development  of  the  ordinary  micro- 
organisms of  suppuration  is  still  unexplained,  but  is  not  doubted  by 
any  practical  surgeon.  IMosetig-Moorhof  tirst  demonstrated  its  great 
eftieacy  in  preventing  septic  processes  in  wounds  freely  conmuuiicating 
with  the  orifices  of  the  digestive  tract,  notably  the  oral  cavity.  Subse- 
cjuently  it  was  emploj-ed  with  great  success  in  wounds  around  the  anus 
and  rectum  or  the  vagina  or  bladder ;  finally  in  wound-cavities  of  any 
description  that  recpiired  temporary  or  prolonged  packing,  ultimately  even 
in  the  peritoneal  cavity  (Mikulicz). 

But  whenever  iodoform  is  employed  it  must  be  used  with  caution, 
especially  in  anajmic  and  elderly  subjects,  as  dangertuis  fiirms  of  intoxi- 
cation are  apt  to  follow  its  indiscriminate  and  unrestricted  exhibition. 
Another  drawback  is  the  tendency  of  iodoform  to  ]iroduce  in  certain 
persons  an  angry  eczema. 

The  iodoform  powder  itself  may  be  the  carrier  of  infection  ;  hence  it 
ought  to  be  washed  in  a  solution  of  corrosive  sublimate  before  use.  The 
best  method  of  impregnation  of  dressings  with  iodoform  is  the  mechan- 
ical one,  which  is  preferable  to  that  by  the  use  of  ethereal  solutions, 
which  are  very  apt  to  decompose.  Crystalline  powder  of  iodoform  is 
simply  scattered  as  evenly  as  possible  over  the  moistened  gauze,  then 
rubbed  into  its  meshes  by  luuul.  (xauze  thus  ])repared  nuist  be  kept  in  a 
tight  receptacle  to  prevent  its  drying,  which  is  still  furtiier  j)rcvented 
by  the  addition  of  a  little  glycerin  to  the  plain  boiled  water  used  for 
moistening.  Light  will  also  tend  to  decompose  iodoform ;  hence  the 
powder  and  iodoform  gauze  ought  to  be  kejit  in  vessels  that  exclude 

When  iodoform  gauze  is  badly  borne,  or  where  its  use  is  contraindi- 
cated  for  other  reasons,  the  powder  of  siihnitratc  of  bismuth  might  be 
advantageously  substituted ;  or  the  gauze  might  be  moistened  with  either 
a  3  per  cent,  solution  of  cwctate  of  alumina  (Burow's  solution)  or  a  1  per 
cent,  solution  of  chloride  of  zinc. 

In  regard  to  the  technique  of  tamponade  the  following  hints  may  be 
found   useful  :  The   width  and   Icny-th  of  the  strips  of  ffiuize   used   for 


G!).S     THE  TECHNIQUE  OF  ANTISEPTIC  AND  ASEPTIC  SUROERY. 

jiiickings  should  be  regulated  by  the  shape  and  extent  of  the  cavity  to  be 
Hllcd.  Each  rcocss  ought  to  receive  a  strip  of  its  own  ]iacked  down 
loosely  and  its  end  lirouglit  out,  corresponding  to  the  location  of  the 
recess.  The  end  of  each  stri|)  must  ]>rotrude  from  the  wound,  otluTwise 
it  might  become  lost.  When  very  large  cavities  are  to  Ite  treated,  it 
might  be  objectionable  to  use  the  large  amount  of  iodoform  gauze  retpu- 
site  for  filling  the  space.  Here  an  ample  compress  of  iodoform  gauze 
ought  to  be  made  to  serve  as  a  /iniiif/  of  the  cavity,  the  central  space 
being  filled  with  strips  of  jilain  or  medicated  gauze  other  than  iodoform. 
The  oozing  of  serum  out  of  tamponaded  wounds  is  often  very  copious. 
Plere  the  superficial  dressings  slnjuld  he  changed  frequently.  After  the 
lapse  of  twice  or  three  times  twenty-four  hours  the  packings  have  to  be 
removed  or  renewed  when  secondary  sutures  are  contemplated — as,  for 
instance,  from  amputation  wounds  or  the  peritoneal  cavity.  From  the 
mouth,  larynx,  circumrectal  sjtaces,  or  the  bladder  the  packings  are  not 
removed  until  they  become  loosened,  unless  special  indications  compel 
their  earlier  withdrawal.  Whenever  the  packings  of  a  septic  wound 
are  removed,  it  is  well  to  observe  a  system  or  order  in  removing  them. 
As  soon  as  a  strip  is  removed  it  ought  to  be  replaced  at  once  by  another 
clean  strip,  then  another  strip  is  removed  and  replaced,  and  so  on  until 
the  entire  wound  is  cared  for  ;  otherwise  recesses  might  be  overlooked  and 
thus  give  rise  to  retention.  Where  special  precaution  is  demanded,  as, 
for  instance,  in  the  removal  of  tamjions  covering  intestinal  sutures,  these 
tampons  must  be  marked  by  tying  a  knot  in  their  distal  end. 

As  most  of  the  dressing  material  used  by  the  general  practitioner  is 
necessarily  derived  from  drug-stores,  it  would  seem  very  desirable  for  the 
manufacturers  of  dressings  to  adopt  a  method  of  sterilization  by  steam, 
according  to  which  the  dressings,  put  up  previously  in  suitable  paper  or 
muslin  packages,  were  to  be  subjected  to  sterilization  irithiit  oikI  together 
vufh  their  c/oaed  wrappings.  Thus  the  contents  of  each  package  would 
certainly  remain  sterile  until   needed. 

VI.  Sponges  and  their  Substitutes. 

For  the  rapid  and  thorough  removal,  during  the  progress  of  various 
operations,  of  blood,  and  in  some  instances  of  pus,  sponges  are  indis- 
pensable. All  the  ditferent  substitutes  that  have  been  suggested  instead 
of  sponges  lack  the  imique  qualities  of  a  good  sponge.  Its  softness, 
the  avidity  with  which  it  absorbs  liquids,  and  the  readiness  with  which 
it  yields  them  on  pressure,  are  all  due  to  the  incomparal:)le  elasticity  and 
porousness  of  its  substance.  Fortunately,  we  liave  in  this  country  a 
cheap  and  abundant  snjiply  of  reef  spniu/es,  chiefly  In-ought  from  Florida. 
and  the  Bahamas.  They  possess  all  the  main  qualities  of  a  good  sponge, 
and,  being  very  inexpensive  (about  $2.00  to  |2.50  a  pound),  need  not  be 
used  oftener  than  once  in  aseptic  cases.  Those  saved  from  an  aseptic 
operation  can  be  resterilized,  and  are  excellent  for  operations  on  septic 
wounds. 

The  difficulty  of  a  reliable  disinfection  of  sponges  has  been  well  rec- 
ognized by  practical  surgeons  since  early  times,  and  the  search  after  a 
good  method  of  cleansing  has  resulted  in  a  number  of  propositions.  One 
of  the  oldest  procedures  is  as  follows  :  The  sponges  are  thoroughly  freed 


SPONGES  AXD   THEIR  SUBSTITUTES.  iiW 

from  calcareous  matter  by  beatintr  witli  a  stick  ;  are  then  immersed  for 
twenty-four  hours  in  a  watery  sokitiou  of  permanganate  of  potash, 
1  :  500,  from  \\  hich  they  are  transferred  into  a  1  per  cent,  sokition  of 
subsulphate  of  soda,  to  which  is  added  pure  muriatic  acid  in  the  propor- 
tion of  8  per  cent,  of  the  volume  of  the  subsulphate-of-soda  solution. 
Tliis  bleaches  the  sponges  and  frees  them  of  the  renuiant  of  calcareous 
dust.  After  this  follows  a  thorougii  rinsing  in  water  and  immersion  in 
a  5  per  cent,  solution  of  carlxilic  acid,  and  the  lunger  the  bt'tter,  as  a 
short  immersion  is  often  insutticient  for  a  thorougii  sterilization.' 

Kiinmiel's  plan  is  very  much  simpler,  but  still  less  reliable.  How- 
ever, it  would  be  improper  to  condemn  it  altogether,  as  it  has  been  found 
excellent  and  very  reliable  after  the  addition  of  a  few  simj)le  improve- 
ments of  the  method. 

Gerster's  modification  of  Kiimmel's  method  is  as  follows :  The 
sponges  are  beaten,  then  immersed  for  twenty-four  hours  in  an  8  per 
cent,  solution  of  muriatic  acid  to  free  them  of  calcareous  sand.  After 
this  they  are  rinsed  in  cold  water  and  put  in  a  closed  jar  filled  with 
water  in  a  warm  place  for  three  days.  During  this  time  the  spores  con- 
tained in  the  meshes  of  the  sponge  all  germinat(%  and  thus  become  more 
sensitive  to  the  infiuence  of  germicides,  and  hardened  collections  of  tilth 
are  also  macerated  and  softt'ued.  After  three  days  the  sjionges  are 
thrown  into  a  vessel  containing  hot  water,  and  each  sponge  is  thoroughly 
kneaded  and  rubbed  with  green  soap,  which  carries  the  maceration  and 
softening  of  the  dirt  adhering  to  the  meshes  to  such  a  point  that  most  of 
it  is  removed  by  a  subsequent  rinsing  in  cold  water.  Each  sponge  is 
now  dipped  in  alcohol,  S(jueezed,  and  thrown  into  a  jar  containing  either 
a  solution  of  corrosive  sublimate  1  :1000,  or  a  o  per  cent,  solution  of 
carbolic  acid,  in  which  it  remains  until  needed,  (^n  account  of  the  pre- 
cipitation of  the  mercurial  salt  the  sublimate  solution  ought  to  be  re- 
newed every  few  weeks.  In  carbolic  acid,  which  is  more  durable,  the 
sponges  are  apt  to  turn  brown,  which,  however,  does  not  diminish  their 
usefulness. 

The  simplest  and  most  conveni(>nt  mode  of  disinfection  by  boiling  in 
soda  solution  cannot  be  employed  with  sjionges,  as  their  softness  and 
elasticity  are  destroyed  by  excessive  hardening  and  shrinkage.  Dry 
heat  will  sterilize  them  thoroughly,  but  will  also  cause  shrinking  and 
hardening  unless  the  sponge  is  first  freed  from  every  trace  of  atmo- 
spheric moisture — a  somewhat  difficult  and  impracticable  process. 

Schimmelbnsch  -  has  devised  the  simplest  and  best  mode  of  disinfect- 
ing sponges,  which  has  stood  the  severest  tests  both  of  practical  expe- 
rience and  of  bacteriological  scrutiny.  The  sponges  are  first  freed  from 
sand  in  the  usual  manner,  then  ai'e  rinsed  in  cold  water,  in  which  they 
are  left  to  macerate  "for  a  week  or  so.  After  this  they  are  cleansed  of 
gross  dirt  by  washing  in  warm  water,  from  wliich  they  are  taken  and 
enclosed  in  a  nuislin  bag.  In  the  mean  time  a  suitable  quantitv  of  a  1 
per  cent,  soda  solution  is  brought  to  the  boiling-point  in  a  pot  or  boiler. 
As  soon  as  it  is  boiling  freely  the  pot  is  withdrawn  from  the  fire,  and 
into  this  scalding  solution  the  bag  of  sjjonges  is  immersed  for  thirty 

'  Frisch  :  "  Ueber  Desinfection  von  Seide  und  Schwiimmen,"  Arckiv  fiir  klin.  C/tir., 
1888,  p.  749 

^  Anleiluny  zur  asept.  Wundbehandtung,  p.  116. 


700     THE  TECHNIQUE  OF  ANTISEPTIC  AND  ASEPTIC  SVIKIERY. 


Fig.  183. 


niinutcfi.  The  soda  solution  will  retain  u  teni]>eratiire  of  from  80  to 
DO  degrees  Celsius  for  a  considerable  time,  and  tiiis  is  sufficient  to 
destroy  all  germs,  even  the  \erv  resistant  an- 
thra.x  s])ores,  within  ten  minutes  (Beliring). 
After  thirty  minutes  tiie  l)ag  is  removed  from 
the  l)oiler,  and  the  sponges  arc  lilicratcd  of  their 
c<»ntents  of  s(Kla  by  rinsing  in  plain  Itoiled  water, 
which  should  be  done  while  the  sponges  are 
still  within  the  bag.  Finally,  they  are  ])laeed 
in  snldimate  or  carbolic  .solution  until  rccpiircd 
for  use. 

xV  fair  sul)stitutc  for  sponges  are  tiie  xpoiigiiii/ 
pads  ("  Tupfer")  used  by  a  number  of  surgeons 
exclusively  and  in  preference  to  sponges,  and 
employed  by  all  in  emergencies.  They  consi.st 
cither  of  a  square  piece  of  absorbent  sterilized 
gauze,  10  by  10  inches,  crushed  into  a   ))all,  or 

Mop,  a  substitute  of  the  sponge.    ~,.  ,,   '  ,.  /-n     i       •,!  •,! 

ot  a  smaller  square  oi  gauze,  hlled  cither  with 
sterilized  moss,  wood-wool,  or  absorbent  cotton,  and  tied  in  a  neck  with 
sterilized  cotton  thread. 


Fin.  184. 


Vn.  Sutures  and  Ligatures. 

The  substances  used  for  tying  vessels  and  for  the  appro.ximation  of 

the  edges  of  wounds  by  suture  are  either  absorbable  or  nou-absorbalde. 

Non-absorbable  are  silk,  silkworm  gut,  cotton  thread,  hor.se-hair,  and 

silver  wire.     Their  sterilization  can  be  reliably  done  either  by  boiling 

in  soda  solution  or  by  exposure  to  a  current  of 
steam,  the  former  at  the  same  time  with  the 
instruments,  the  latter  with  the  dressings.  The 
non-irritant  quality  of  any  one  of  these  sub- 
stances depends  entirely  and  solely  upon  their 
freedom  from  noxious  germs,  and  on  nothing 
else.  Hence  if  they  are  to  be  buried  in  the 
tissues  it  is  advisable  to  sulijcct  silk  and  silver 
wire  to  a  thorough  disinfection  juxt  before  use. 
Tiie  silk  employed  in  suturing  may  be  .steril- 
ized once,  and  then  preserved  in  a  tight  vessel 
containing  citlier  carbolic  or  sublimate  solution. 
Of  absorbable  threads  there  are  catgut  and 
ktingaroo  tendon  (Marcy).  The  endeavor  of  the 
older  surgi'ons  to  gain  an  al)sorI)ali]e  material 
for  ligatures  led  to  the  tentative  eiiij>loymciit  of 
buckskin,  the  aorta  of  the  ox,  fresh  intestinal 
fibre,  fresh  tendon,  and  raw  hide  ;  and  the 
Metni  case  for  steam-sterilized   great  advantage  of  a  material  that,  after  hav- 

dry  silk  (SeliimiiK'lt)iisch).         v  /.  i    . ,      ^         ,.  t  -j.!        a 

ing  ))eriormed  its  tunction,  ih.sappears  without 
any  further  aid,  is  very  evident.  Moreover,  it  is  well  known  that 
many  aseptically  buried  silk  or  wire  threads  will  ultimately  work  out 
to  tiie  surface,  though  this  may  happen  without  active  suppuration. 
Hence  we  owe  a  debt  of  gratitude  to  Lister,  who  .systematically  iiitro- 


SUTUEES  AXD  LIGATURES. 


(01 


duced  animal  or  oatji'iit  ligatures  into  surgical  practice.  Catgut,  long 
since  in  use  on  musical  instruments  and  in  certain  trades,  is  made  of  the 
fibrous  portion  of  the  nuiseularis  of  the  small  intestine  of  sheep. 
The  process  of  maceration,  liy  which  the  nuieous,  serous,  and  circular 


Fig.  is.-,. 


(ilass  jar  U>v  wet  cat^ait  or  silk. 

muscular  constituents  of  the  intestinal  wall  are  prepared  for  their 
mechanical  removal,  involves  decomposition,  and  ]>ermeation  with  mil- 
lions of  miero-organisius,  aioong  which  the  spores  and  Itacilli  of  anthrax 
may  be  and  have  been  represented  (Volkmann).  Therefore  a  thorough 
disinfection  of  catgut  becomes  one  of  the  most  important  desiderata  of 
clean  surgery.  Of  Lister's  original  method,  of  disinfection  by  immer- 
sion in  carbolized  oil,  it  need  only  be  said  that  it  is  entirely  inadequate, 
and  has  been  universally  abandoned. 

Lixter'n  vhromichcd  citfr/uf  offers  more  security  against  infection, 
because  chromic  acid,  a  strong  germicide,  is  employed  in  addition  to 
carbolic  acid,  and  the  solutions  used  are  aqueous,  not  oleaginous;  hence 
much  more  etfective.  The  object  of  the  addition  of  chromic  acid,  how- 
ever, was  not  the  attainment  of  a  more  complete  asepticism,  but  a  hard- 
ening of  the  gut  to  prevent  its  too  rajiid  or  ])remature  absorption. 

Chromicized  catgut  is  prepared  as  follows  :  To  a  5  per  cent,  carbolic- 
acid  watery  solution  is  added  crystalline  chromic  aci<l  in  the  jiroportion 
of  1  :  4000,  in  which  the  catgut  remains  inunersed  for  forty-eight  hours. 
Then  it  is  taken  out,  dried,  and  kept  in  carbolized  oil,  1  :  5. 

Koclier'ii  preparation  wifh  oil  of  juniper  has  yielded  good  results, 
though  it  has  led  to  failures  ii:  the  hands  of  Kocher  himself.  Cats;ut  is 
placed  in  the  oil  of  the  berry  of  juni|)er  for  twenty-four  hours;  then  it 
is  taken  out  and  kept  in  absolute  alcohol. 

Bcrr/mnnn's  procedure  is  very  reliable,  and  can  be  warndy  recom- 
mended. First,  the  vessel  to  serve  as  a  reccjitacle  is  sterilized  in  steam 
for  three-quarters  of  an  hour  ;  then  raw  catgut  is  wound  u])on  suitable 
glass  bobbins,  and  is  placed  in  sulphuric  ether  for  twenty-four  hours  to 
free  it  from  fat.     X(jw  the  ether  is  j)oured  off  and  replaced  by  a  solution 


702     THE  TECHNIQUE  OF  ANTISKPTJC  AND  ASEPTIC  SURGERY. 

of  corrosive  suhliiiuite  10  parts,  al)S(iliit('  alcohol  800  parts,  and  dis- 
tilled water  200  parts.  This  alcoholic  solution  becomes  turbid  after  a 
day,  and  should  be  renewed  twice.  After  three  times  twenty-f(jur  hours 
the  sublimate  solution  is  replaced  bv  absctlute  alcohol,  in  which  the  cat- 
gut is  kcjit  permanently. 

The  methods  of  sttTilization  by  boiling  and  steaming  arc  not  a])])li- 
cable  to  catgut  unless  another  medium  than  water  is  employeil.  I5run- 
ner's'  j:)rocess  by  boiling  in  xylol,  and  Dowd's  in  alcohol,  arc  both  com- 
plicated, and  not  more  reliable  than  Bergmann's  plan. 

The  modus  of  the  absorption  of  catgut  buried  in  living  tissues  has 
been  studied  by  Ijcsser'-and  others,  and  consists  first  of  .swelling  by 
imliibition  ;  then  its  interstices  are  invaded  by  leucocytes,  to  be  soon 
followi'd  by  granulation  tissue,  under  the  influence  of  which  it  becomes 
disintegrated  and  assumes  the  character  of  detritus,  which  is  gradually 
carried  away  by  the  lymphatic  circulation. 

Vm.  Drainage. 

Since  Chassaignac,  who  was  the  first  to  use  it,  systematic  tubular 
drainage  has  remained  firndy  established  in  surgery.  It  is  true  that  its 
scope  lias  been  considerably  curtailed  by  simple  canalization  (Neul)er) 
and  capillary  di'ainage  ;  still,  in  the  vast  field  of  suppurative  affections 
and  in  the  surgery  of  certain  cavities  tubidar  drainage  remains  indis- 
pensable. 

The  selection  of  the  jtrojicr  form  of  drainage  must  depend  u])on  the 
nature  of  the  discharge  to  be  drained  away.  Where  serinn,  or  bloody 
serum  of  an  aseptic  character,  is  to  be  expected,  esjiecially  when  the 
shajie  of  the  wound  is  not  comjilicated  and  not  too  deep,  capillary  drain- 
age by  the  aid  of  a  few  strands  of  horse-hair  or  catgut  will  be  in  place, 
or  even  the  leaving  of  one  or  more  angles  of  the  wound  slightly 
patulous,  or  the  placing  of  sparser  suture-points,  will  be  found  sufficient, 
iSniall  wounds  can  be  tightly  closed  without  any  drainage  [f  the  siirc/eon's 
aseptic  mensiires  are  perfect.  Even  as  large  Mounds  as  those  made  in 
amiiutation  of  the  mamma  have  been  habitually  closed  by  the  author 
with  sutures  without  any  drainage,  and  out  of  29  cases,  in  28  healing 
took  place  without  trouble  and  by  the  first  intention.  But  in  the  twenty- 
ninth  the  ]>atient  came  very  near  losing  her  life  by  acute  sepsis  inadver- 
tently carried  into  the  wound  at  the  time  of  the  operation  from  a  neigh- 
boring patient  suffering  from  acute  osteomyelitis.  Before  the  wound  was 
examined  extensive  sloughing  of  the  fasciie  and  of  the  outer  skin  took 
place. 

From  tubular  drainage  where  thick,  consistent,  and  rojiy  masses  of 
))us  are  to  be  carried  out  of  a  cavity,  to  capillary  or  no  drainage  where 
a  perfectly  dry  and  asejitic  wound  treated  without  chemicals  promises 
to  remain  dry  and  aseptic,  the  transitions  and  gradations  are  many,  and 
their  proper  selection  and  adaptation  must  depend  on  the  skill  and  judg- 
ment of  the  surgeon. 

Whatever  material  is  to  be  employed  for  drainage,  it  is  indispensable 
that  it  should  be  made  absolutely  sterile  before  use. 

'  "Uelier  Catgiitinfection,"  Bdlrdge.  filr  hlin.  Ckir.  (Bruns.),  1890. 
2  "  Ueber  das  Verhalten  des  Catgut,"  Virchmh  Arch.,  vol.  95,  1884. 


LOTIONS,  IRRIGATING  SOLUTIONS,  ETC.  703 

Neuber's  absorbable  drainage-tubes,  prepared  out  of  decalcined  ox- 
bones,  and  siuiilur  ones  made  of  the  lonjj  bones  of  large  l)irds  (Trendelen- 
burg, ^laeEweu),  have  all  been  abandoned  as  inipraetieal.  Glass  drain- 
age-tubes are  very  neat  and  clean,  and  can  be  readily  sterilized,  btit  are 
rigid,  fragile,  and  cannot  be  shortened  to  suit  varying  conditions ;  hence 
they  have  come  into  use  only  here  and  there.  Rubber  drainage-tubes  are 
still  considered  the  most  adaptable,  cheap,  and  useful  material  for  wound- 
drainage.  Their  disinfection  can  be  safely  done  by  boiling  for  five 
minutes  in  soda  solution  (1  per  cent.)  or  by  steaming  during  fifteen  to 
twcutv  minutes.  Tiiis  will  not  harm  the  rubber.  After  disinfection 
the  tubes  ought  to  be  preserved  by  preference  in  a  5  per  cent,  solution 
of  carbolic  acid,  which  will  not  become  inert  by  contact  with  rubber,  as 
will  corrosive  sublimate.  The  best  receptacle  is  a  tall  fruit-jar.  The 
tubes  should  be  cut  into  proper  lengths — that  is.  a  little  shorter  than  the 
height  of  the  jar — and  are  to  be  put  in  ujjright — that  is,  standing  on  end 
— to  facilitate  removal. 

IX.  Lotions,  Irrigating  Solutions,  and  Antiseptic  Powders. 

Water,  the  usual  solvent  in  preparing  lotions,  is  never  free  from  germs 
when  found  in  its  natural  state  in  springs,  wells,  running  water,  ponds, 
lakes,  and  the  ocean.  Only  in  the  state  of  very  deep  ground-water  and 
as  atmospheric  vapor  is  it  known  to  be  germless.  As  soon  as  it  apjjroaches 
the  earth's  surface,  either  from  below  (sjirings)  or  from  above  (rain),  it 
becomes  ciiarged  with  micro-organisms,  which  are  often  pathogenetic. 
Sea-water  also  contains  pathogenetic  germs  near  the  shores,  where  it 
mingles  with  the  drainage  of  inhabited  areas  of  land. 

To  be  admissible  for  surgical  use  water  must  be  freed  from  its 
mici'obial  contents.  This  can  be  done  by  precipitation,  by  filtration, 
by  boiling,  and,  finally,  by  the  addition  of  chemical  germicides. 

Finely-])owdered  insoluble  substances  mixed  with  water  will,  on  set- 
tling to  the  bottom,  carry  with  them  into  the  sediment  a  certain  propor- 
tion of  the  microbes  suspended  in  the  water.  The  finer  the  powder  and 
the  slower  the  process  of  sedimentation,  the  better  will  the  water  be 
purifieil,  but  ;i  perfect  state  of  sterility  can  never  be  reached  by  this 
method. 

Filtration  by  the  various  usual  methods  will  very  materially  diminish 
the  number  of  germs  contained  in  the  water  from  lakes  and  rivers.  The 
filters  of  the  waterworks  of  the  city  of  Berlin,  for  instance,  are  .so  effect- 
ive as  to  reduce  the  number  of  microbes  contained  in  a  cubic  centimetre 
of  the  water  of  the  river  .Spree  from  hundreds  of  thousands  to  an  aver- 
age of  from  fifty  to  seventy.  Here  the  filtering-beds  are  made  of  gravel 
and  sand.  But  even  where  tight  porous  vessels  made  of  ])ottcr's  earth 
(Chamberland-Pasteur)  or  of  "an  impalpable  powder  (like  Kicselguhr ' ) 
are  used,  the  certainty  of  an  alisolutc  detention  of  all  microbes  in  the 
filtering  medium  is  assured  only  for  a  certain  time.  In  addition  to  this, 
large  (luantities  of  water  cannot  be  treated  by  tliis  method  in  a  practical 
manner. 

Boiling  is  far  superior  to  either  sedimentation  or  filtering.  Almost 
all  of  the  germs  contained  in  water  are  surely  destroyed  by  boiling  for 

'■  Nordtmayer:  "  I'eber  Wasserliltration,"  Zeituchrift  fiir  Hi/i/iene,  vol.  .x.,  IS'Jl,  j).  1-15. 


704     THE  TECHNIQUE  OF  ANTISEPTIC  AND  ASEPTIC  SVIUIERY. 

five  minutes,  and  tliis  ajiplies  to  tlic  dirtiest  :is  well  as  to  the  cleanest  water. 
Dor  and  Vinay,'  who  boiled  the  water  of  tiie  river  Khone,  eontainin>j  an 
average  of  33,000  germs  per  litre,  found  that  only  941  of  them  survived 
tiic  process ;  that  is,  more  than  97  per  cent,  were  destroyed.  In  addition 
to  this  it  must  be  said  that  the  germs  eapal^le  of  surviving  the  ordeal  of 
boiling  are  not  pathological ;  as,  for  instance,  the  hay  l)aeillus.  The 
method  commends  itself  for  its  simplicity,  safety,  and  general  appli- 
cability;  hence  in  important  cases  it  will  be  good  for  the  surgeon  to 
provide  an  ample  quantity  of  boiled  water.  The  dipper  or  pitcher  to 
be  used  for  ladling  should  be  boiled  together  with  the  water.  In  hospi- 
tals running  hot  water  is  provided  from  a  central  boiler. 

But  even  this  simple  method  of  sterilizing  water  bv  boiling  is  not 
always  applicalde  ;  therefore  it  is  very  convenient  to  have  another,  more 
ready  way  of  accomplishing  the  same  result  by  the  addition  of  a  chem- 
ical germicide  to  the  water.  On  account  of  the  fact  that  the  microbes 
contained  in  ordinary  pure  water  are  widely  distributed,  and  not  collected 
in  dense  masses,  hence  freely  accessible  from  all  sides,  their  destruction 
by  chemicals  readily  dissolved  in  the  medium  is  not  difficult.  Not  so 
easy  is  the  disinfection  of  the  turbid  and  much-polluted  waters  of  canals, 
ponds,  and  stagnant  pools  located  near  human  hal)itations.  The  cause 
of  this  is  to  be  sought  in  the  fact  that  these  waters  contain  smaller  and 
larger  lumps  of  gross  dirt  of  varying  density,  aggregations  of  organic 
matter  teeming  with  microbial  life.  To  render  chemical  disinfection 
possible,  such  water  must  be  first  })urged  of  gross  filth  by  filtration. 
iShould  this  not  be  feasible,  boiling  will  have  to  be  resorted  to,  and  w  ill 
prove  even  here  fully  effective. 

Where  only  the  mechanical  effect  of  a  lotion  is  desired,  as  in  many 
aseptic  operations,  the  phj'siologically  nnirritant  solution  of  common 
cooking  salt,  6  to  sterilized  water  1000,  Mill  be  found  convenient.  This 
solution  does  not  cause  smarting  in  a  fresh  wound. 

The  most  effective  and  most  useful  of  all  chemical  germicides  is  corro/iive 
sublimate,  suggetited  by  Koch  and  introduced  into  surgical  practice  by  Berg- 
mann.  It  is  a  very  poisonous  and  very  cheap  ^vhite,  crystalline,  odorless 
powder,  readily  dissolved  in  water  and  promj>tly  decomposed  by  contact 
with  metals.  Hence  it  cannot  be  used  for  the  disinfection  of  instruments, 
nor  can  it  be  kept  in  metallic  vessels.  As  connnou  drinking-water  often 
holds  in  solution  considerable  quantities  of  the  alkaline  earths,  notably 
lime,  which  eagerly  decompose  the  mercurial  salt,  forming  insoluble 
deposits,  it  is  necessary  to  counteract  this  tendency  by  the  addition  to 
the  solution  of  some  acid.  Either  acetic  or  tartaric  acid,  or  finally  com- 
mon cooking  salt,  will  perform  this  service,  a  good  rule  being  to  take 
either  of  these  correctives  in  the  same  proportion  as  the  corrosive  sulj- 
limate.  To  a  1  :  1000  solution,  for  instance,  would  be  taken  1  gramme 
of  corrosive  sublimate,  1  gramme  of  cooking  salt,  and  1000  grammes  of 
water. 

Corrosive  sublimate  is  used  in  solutions  of  1  :  5000  f)r  continuous 
irrigation  during  prolonged  operations  about  the  anus ;  1  :  2000  and 
1  :  1000  for  washing  septic  wounds,  and  for  disinfecting  the  skin  of 
patient  and  surgeon;  1  :  500  for  the  final  disinfection  of  bone-cavities 
after  necrotomy  to  prepai'e  them  for  Schede's  plan  of  after-treatment. 

'  "  De  la  sterilisation  de  I'eau,  etc.,"  Lyon  medical,  1889,  No.  23. 


LOTIONS,  IRRIGATING  SOLUTIONS,  ETC.  705 

A  very  convenient  mode  of  preparing  snblimate  solutions  is  that  by 
means  of  sublimate  tablets  sold  by  the  drug-firms.  Transportation  and 
dosage  are  very  easy.  In  the  absence  of  tablets  the  surgeon  will  prepare 
a  concentrated  alcoliollc  laothcr-solufion,  from  wliieh  tiie  weaker  solutions 
are  made  as  reipiired.  A  10  per  cent,  solution  w\\\  be  found  very  useful 
and  not  too  bulky.  Two  teaspoonfuls  of  this,  added  to  a  cjuart  of  water, 
will  give  the  proportion  of  about  1  :  1000.  For  the  transportation  of 
this  strong  solution  a  glass-stoppered  bottle  in  a  wooden  case  will  be 
needed. 

The  symptoms  of  systemic  sublimate  poisoning,  caused  by  indis- 
criminate use,  are  those  of  an  intense  enteritis  with  colicky,  often  bloody, 
stools  and  salivation.  Local  irritation,  assuming  the  form  of  an  angry 
dermatitis,  is  often  caused  by  moist  sublimate  dressings. 

Carbolic  acid,  Lister's  original  disinfectant,  forms  colorless  crystals 
when  undissolved.  It  is  volatile  and  strongly  corrosive.  Solutions  are 
prepared  as  follows  :  The  crystalline  acid  is  liquefied  by  moderate  heat; 
then  water  is  a<lded  in  due  projiortion.  Its  usual  solutions  are  the  weaker 
one,  1  or  2  per  cent.,  for  the  innnersion  of  instruments,  for  lotiiins  and  irri- 
gation, and  the  stronger  solution,  5  per  cent.,  for  tlie  disinfection  of  septic 
wounds,  and  for  irritant  injections  into  joints,  cysts,  or  hydrocele.  This 
solution,  freely  applied  to  a  fresh  wound,  will  produce  a  grayish  glaze, 
due  to  superficial  corrosion  of  tlie  tissues.  It  is  very  poisonous,  espe- 
cially to  small  children. 

One  of  the  first  symptoms  of  carbolic  poisoning  is  the  characteristic 
olive-green  coloring  of  the  urine.  It  is  soon  followed  by  headache, 
vertigo,  fainting,  vomiting,  irregular  breathing,  and  a  thready  pulse. 
In  severe  cases  coma,  contracted  rigid  pu]>ils,  clonic  muscular  spasms, 
pulselessness,  suppression  of  urine,  and  intestinal  hemorrhages  often 
lead  to  a  fatal  termination.  The  skin  is  also  very  sensitive  to  carbolic 
acid,  often  responding  to  its  irritant  action  liy  fiorid  eczema.  Strong 
solutions  of  carbolic  acid  applied  to  small  members,  as  the  fingers  and 
toes,  often  cause  a  dry  form  of  gangrene. 

Creolin,  mixed  with  water,  forms  a  milky  lotion,  which  is  about 
three  times  as  eifective  as  carbolic  acid.  The  usual  prop(irtions  are  1 
and  2  per  cent.     Its  odor  is  very  disagreeable,  but  it  is  non-poisonous. 

Lysol,  like  carl)olic  acid  and  creolin,  is  a  coal-tar  pi'oduct.  It  is  a 
poisonous,  soapy  liquid,  which  yields  a  somewhat  less  turbid  solution 
with  water  than  creolin,  and  is  about  as  effective. 

Salici/lic  acid  (Thiersch),  a  good,  though  weak,  non-poisonous  anti- 
se])tic  powder  of  white  color,  is  intensely  irritating  to  the  nasal  and  bron- 
cliial  mucous  membranes.  In  combination  with  boric  acid  it  firms  the 
poptdar  T/iirrsch  solution:  salicvlic  acid  2  parts,  boric  acid  12  pai'ts, 
hot  water  1000  parts. 

Acetate  of  alumina  (Burow's  solution),  a  very  effective,  adstringent, 
and  deodorizing  antiseptic,  is  especially  useful  where  the  skin  is  very 
vulnerable  and  apt  to  become  eczematous  under  the  dressings.  It  is 
also  nuich  used  in  phlegmonous  affections  requiring  permanent  immersion 
or  irrigation.  A  1  per  cent,  solution  is  prepared  by  mixing  24  granunes 
of  alum  with  -''S  grammes  of  sugar  of  lead  in  1000  grammes  of  water. 
After  twenty-four  hours  the  clear  part  siiould  be  decanted  from  the 
insoluble  sedijuent. 

Vol.  I.— to 


70C     THE  TECHNIQUE  OF  ANTISEPTIC  AND  ASEPTIC  SUIlCEUy. 

Tlij/mol  (Ranke),  a  mild,  n()n-])oisonoiis  antiseptic  of  ])k'asaiit  odor, 
non-irritant,  is  used  in  the  stren<;tii  of  1  :  1000. 

l\'nitaiif/an(ii<'  of  jiotaxli  is  a  very  soluble,  mild  disinfectant,  and  a 
strono;  deodorizer,  but  of  evanescent  effect,  as  it  is  prdiiijitlv  ileeoni- 
posed  by  contact  with  the  secretions.  It  is  used  in  the  strength  of 
from  1  :500  to  1  :  2000  as  a  month-wash  and  as  an  irrit^atinfj  fluid  for 
the  urethra  and  bladder. 

Chlorine,  a  very  jiowerful  antiseptic,  is  used  in  the  sliajie  oi'  rhlor'nu- 
water. 

Peroxide  of  hi/drogen  (Troninisdorff ),  a  very  strong  antiseptic  fluid, 
non-poisonous,  is  used  in  the  strength  of  8  per  cent,  for  the  disinl'eetiou 
of  suppurating  and  ill-smelling  wounds  ;  is  also  a  good  sty])tic. 

Certain  aniline  dyes,  as  methyl-blue  and  pyoktanin  (Stilling),  are  of 
undoul)ted  antiseptic  value  in  the  treatment  of  ulcerating  and  sloughing 
malignant  new  growths. 

Among  the  antiseptic  powders,  iodoform  is  to  be  flrst  mentioned.  It 
is  a  light-yellow,  crystalline  powder  of  peculiar  odor,  non-soluble  in 
water,  soluble  in  alcohol,  ether,  and  some  oils.  Its  antiseptic  ]iro])erties 
are  developed  indirectly  by  contact  with  the  products  of  microbial  decom- 
position (ptomaines  and  toxalbmnin).  Their  chemical  actii)n  liberates 
a  certain  [u-oportion  of  free  iodine,  which  inhibits  a  further  development 
of  microbes.  It  is  very  poisonous,  especially  to  elderly  and  antemic 
subjects,  and  often  is  also  very  irritant  to  the  skin.  Its  offensive  odor 
can  be  effectively  masked  by  an  admixture  of  burnt-coffee  powder  and 
.some  aromatic  oils.  It  is  used  for  dusting  the  line  of  union  of  a  sutured 
wound,  and  most  effectively  in  the  vicinity  of  the  natural  a])ertures  of 
the  human  Ixidy,  where  perfect  asepsis  is  not  attainable.  In  tiic  sha]ie 
of  iodoform  glycerin,  from  10  to  20  per  cent.,  it  is  injected  with  good 
effect  into  tuberculous  foci.  A.s  iodoform  gauze  it  is  an  indispensable 
aid  in  treating  wounds  communicating  with  the  oral  cavity,  the  rectum, 
vagina,  and  bladder,  in  the  temjwrary  tamjxjnade  preceding  secondary 
.suture,  in  forming  a  protective  dam  against  infection  of  the  healthy  ])eri- 
toneum  in  operations  for  appendicitis;  finally,  in  plugging  irregular 
denuded  cavities  caused  by  various  intra-abdominal  ojicrations. 

The  symptoms  of  iodoforni-poisoning  are  rubescence  of  the  skin, 
headache,  dejection,  nausea,  and  vomiting ;  in  the  more  serious  cases, 
sleeplessness*  great  frequency  of  the  ))ulse,  restlessness,  fever,  delirium, 
maniacal  attacks,  finally  coma  and  convulsions.  In  these  cases  iodine 
is  found  in  the  urine,  in  wiiieli  its  jm-scnce  is  demonstrated  by  the  addi- 
tion of  dilute  sulphuric  acid  and  fuming  nitric  acid,  together  with  a 
small  quantity  of  chloroform.  If  this  mixture  is  violently  shaken,  the 
chloroform  assumes  a  purjile  color  under  the  influence  of  free  iodine. 

Subnitrafe  of  bi.wuitli  (Kocher)  is  a  good  antiseptic  powder,  though 
somewhat  poisonous  if  used  in  large  quantities.  It  is  a  strong  exsic- 
cative. 

Xaphtlwline  (E.  Fischer)  is  also  a  good,  non-poisonous,  but  very  ill- 
smelling,  antiseptic  ])owder. 

Oxide  of  zinc,  a  mild  antiseptic  powder,  is  one  of  the  components  of 
Socin's  paste,  which  is  used  for  a  covering  of  small  sutured  ^\•ounds  of 
the  face,  instead  of  regular  gauze  dressings.  Its  formula  is :  oxide  of 
zinc,  50  grammes ;  chloride  of  zinc,  5  grammes ;  Avater,  50  grammes. 


OPERATING-ROOM  AXD  SICK-ROOM.  iH' 

lodol,  sozoiodol,  dcrmafol,  arixtol,  nulphainhiol,  and  salol  are  all  recom- 
mended as  eifective  substitutes  for  iodoform. 

X.  Operating-room  and  Sick-room. 

The  modern  operating-room  should  be  tlie  embodiment  of  what  is 
immaculate.     Everything  tending  to  the  generation  and  accunudation 

Fig.  186. 


.^tand  for  irrigiiturs  and  liasins. 


of  dirt  and  dn.st  .-^liuuld  l)c  l)ani.-.h((l  fnmi  it.      A  tiled  Hoor,  a  tiled  dado, 
the  simplest  and  easily  cleaned  wash-basins,  the  upj)er  part  of  the  walls 


708     THE  TECHNIQUE  OF  ANTISEPTIC  AND  ASEPTIC  SURGERY. 

finislied  in  enamel  paint,  without  cornices,  angles,  or  projections  of  any 
kind — in  short,  everything  of  a  nature  admitting  the  easiest  and  most  rad- 
ical cleansing  by  scruhbing-hriish  and  the  watering-hose — are  necessary. 
The  fiirnitnre,  uperating  and  other  taldcs,  should  be  constructed  of  iron 
and  glass,  and  should  l)c  kept  tidy  and  Itrigiit  by  frequent  wasiiing  and 
the  apjilication  of  white  enamel  jiaiiit.  The  floor  should  be  a  gently 
inclined  plane  and  water-tigiit,  atfordiiig  the  possibility  of  an  unstinted 
use  of  water.  The  sterilizing  apparatus  for  instruments  and  dressings 
has  to  be  within  comfortalile  reach  of  the  operating-table ;  tlie  instru- 
ment-cases, constructed  of  enamelled  iron  and  glass,  ought  to  be  in  a 
side  room,  as  the  al)undant  use  of  water  ami  steam  in  the  operating- 
room,  however  favorable  against  the  creation  of  dust,  is  apt  to  cause 
rusting.  For  the  reception  of  soiled  linen  a  covered  and  enamelled 
metal  receptacle  is  to  be  provided ;  fin"  catching  pus,  ichor,  urine,  cystic 
and  other  pathological  fluids,  glass  pus-basins  and  co^•ercd  l)uckets  will 
be  needed.  All  of  these  must  be  innnediately  removed  from  the  ope- 
rating-room with  their  contents,  and  should  not  be  suflcrod  to  remain 
there  longer  tiian  unavoidably  necessary.  The  dressings  sliould  be  kept 
in  the  closed  metal  boxes  in  which  they  were  sterilized  until  the  moment 
when  they  are  actually  needed  for  use. 

For  the  storing  and  use  of  the  various  irrigating  fluids  an  iron-and- 
glass  stand  is  needed,  on  which  are  disposed  suitable  bottles,  the  con- 
tents of  which  can  be  readily  brought  to  the  wound  by  means  of  rubber 
tubing  and  glass  nozzles. 

An  ample  supply  of  glass  vessels  and  trays,  of  smaller  and  larger 
size,  for  the  laying  out  of  instruments  and  for  the  rinsing  of  hands  and 
sponges  in  antiseptic  or  aseptic  fluids  during  the  course  of  an  operation, 
forms  a  necessary  complement  of  the  outfit  of  the  operating-room. 

Where    the    operating-room    serves    the   purposes    of  teaching,    the 

Fig.  187. 


Simple  operating-table  (Rotter). 


benches  and  seats  provided  for  the  audience  should  be  of  the  simplest 
kind,  admitting  of  an  easy  mode  of  cleansing  by  the  watering-hose 
and  mop. 


OPERATING-ROOM  AND  SICK-ROOM. 


709 


Separate  operating-rooin.s  for  septic  and  for  aseptic  cases  are  very 
desirable,  as  by  attending  to  septic  cases  in  strictly  separate  rooms, 
furnished  with  distinctly  separate  sets  of  instruments,  the  chances  of 
accidental  infection  of  clean  wounds  will  be  considerably  diminished. 
Should  this  dualism  be  impossible,  and  there  be  only  one  room  in  which 
laparotomies,  artiirotomics,  and  operations  for  j)lile!jnionous  atlections 
must  be  dealt  with  one  after  the  other,  then  the  invariable  rule  ought  to 
prevail,  to  do  the  aseptic  operations  first,  and  to  leave  the  work  on  septic 
wounds  to  the  last. 

When,  in  private  practice,  a  living-room  of  the  dwelling  of  the 
patient  is  to  serve  as  an  operating-room,  it  will  be  impossible  to  ci'eate 


Fig.  188. 


Table  for  instruments  and  dressings  (Rotter). 

conditions  of  such  exquisite  cleanliness  as  are  demanded  by,  and  indis- 
pensable in,  the  tainted  surroundings  of  a  hospital.  And,  luckilv,  they 
ar(>  not  necessary,  as  it  is  known  that  the  atmosphere  and  dust  of  private 
dwellings  contain  much  fewer  pathogenetic  germs  than  those  of  hospitals. 
It  is  a  good  rule,  however,  to  select  that  one  of  a  set  of  rooms  wliich  is 
least  inhabited,  and  not  to  disturb  the  furniture  and  hangings  unless  this 
— that  is,  theii-  removal — can  be  done  from  six  to  eight  lK)urs  ]>receding 
the  time  of  tiie  operation.  In  short,  unless  the  clearing  and  cleansing 
of  tiie  room  be  done  a  good  while  before  the  operation,  giving  ample 
time  for  the  settling  of  the  dust,  it  is  better  simply  to  cover  the  tables 
to  be  used  with  clean  white  cloths,  to  wipe  chairs  with  a  wet  towel,  and 
to  avoid  every  unnecessary  disturbance  of  the  rest  of  the  furniture  that 
may  tend  to  stir  up  dust. 

Sick-rooms  or  sici--iranl.-i  require  a  similar  management ;  that  is, 
scrupulous  attention  to  cleanliness,  facilitated  by  the  practical  simplicity 
of  the  utensils  and  fiu'uisiiings.  Glass  and  iron  deserve  the  preference 
over  .so-called  artistic  furniture,  and  all  unnecessary  hangings  and  orna- 
ments should  be  eschewed,  especially  where  we  have  to  deal  with  infec- 
tious forms  of  disease,  as,  for  instance,  di])htheiMa,  profuse  supjinrations, 
typhoid  and  other  fevers,  etc.  In  wards  the  floors  should  be  eitlier  tiled 
or  maile  of  terrazzo,  and  tiien  covered  witli  rugs  in  a  suitable  manner,  or, 
if  they  are  to  be  of  wood,  the  work  should  be  dose-jointed  and  the  sur- 


710     THE  TECHNIQUE  OF  ANTISEPTIC  AND  ASEPTIC  SURGERY. 

face  kept  ln'iii'lit  ami  liiylily  ])iilisli((l  or  cuvcred  witli  a  frequently- 
renewed  eoat  iif  paint. 

Abundant  and  (•iiMif(irtal)lc  liatliiiii;'  provisions  fonn  an  indispensable 
eoncdinitant  of  [jvopcrly  furnisiied  wards  and  siek-rooins. 

The  c/iangc  of  (Ircn.siiujx  is  an  important  function  involving  some 
risk,  and  therefore  must  be  surrounded  by  adequate  safeguards.  Tlie 
first  one  of  these  is  the  strict  separation  of  patients  Avith  infected 
wounds  from  those  whose  wounds  are  aseptic.  Sliould  this  be  imjios- 
sil)le,  tiien  the  clean  cases  ougiit  to  be  attended  to  first,  the  infected 
ones  attended  to  the  last  in  seipicnce.  Wlien  there  is  a  great  accumula- 
tion of  patients,  many  of  whom  require  the  change  of  extensive  and 
bulky  dressings,  it  is  very  desirable,  for  many  reasons,  to  have  a  sepa- 
rate room,  a  so-called  "  dressing-room,"  for  the  renewal  of  all  larger 
dressings,  or,  in  tlie  absence  of  this,  to  change  dressings  in  the  operat- 
ing-room. The  advantages  accruing  from  tliis  plan  are — first,  the  avoid- 
ance of  excitement  among  the  rest  of  the  ]>atients,  who  witness  the  fear 
and  outcries  of  the  individual  whose  dressings  are  being  changed ; 
secondly,  small  corrections  of  the  state  of  the  wound,  such  as  incisions, 
dilatation  of  sinuses,  etc.,  can  be  at  once  performed  as  required,  and 
more  readily  than  in  the  wards  ;  thirdly,  the  soiling  of  the  floors  and 
bedding  and  the  raising  of  dust  from  the  dressings  removed  are  avoided 
in  the  wards. 

Another  safeguard,  too  often  neglected  in  our  hospitals,  is  this  :  that 
surgical  rounds,  necessitating  the  exposure  of  wounds,  shoidd  not  be 
made  directly  after  the  methodical  sweeping  and  dusting. 

Every  year  at  least  once,  l>ut  preferably  twice  or  three  times,  each 
ward  should  be  completely  cleared  of  ]iatients  and  furniture,  and  receive 
a  very  thorough  cleansing  by  the  scrul)l)ing-brush,  soap,  whitewash,  and 
fresh  paint.  No  great  reliance  should  be  placed  in  this  animal  house- 
cleaning  upon  chemical  methods  of  disinfection,  as,  for  instance,  fumi- 
gations with  suljihur,  chlorine,  or  sublimate,  or  washings  with  antiseptic 
lotions.  As  it  is  known  that  the  germs  of  infection  are  imbedded  in 
gross  masses  of  dirt  encrusting  the  surfaces  of  walls,  floors,  door-knobs, 
furniture,  etc.,  the  rational  thing  to  do  is  a  thoroughgoing  mcchanmd 
c/('fn(s/?jr/ of  all  these  articles  with  hot  soda-and-soap  solutions  and  by  the 
scrubbing-brush,  to  be  followed  by  the  application  of  a  fresh  coat  of 
jiaint.  Such  a  radical  cleansing  of  a  ward  or  sick-room  might  be  ren- 
dered necessary  at  any  time  by  the  a]ipearance  of  erysipelas  or  other  forms 
of  infection  with  an  epidemic  tendency. 

XI.  Aseptic  and  Antiseptic  Operating  and  After-treatment. 

To  illustrate  in  a  coherent  manner  the  progress  of  an  aseptic  operation 
we  shall  take  as  an  example  the  account  of  an  amputation  of  the  female 
breast. 

Assuming  that  the  operation  is  to  lie  done  in  the  middle  of  the  day, 
the  patient  should  receive  only  a  light  liquid  breakfast  early  in  the 
morning.  The  operation  should  be  preceded  by  a  full  bath  if  possible, 
and  a  careful  shaving  and  scrubbing  with  soap  and  water  of  the  field 
of  operation,  which  then  should  be  enveloped  in  a  moist  pack  of  towels 
dipped  in  a  weak  sublimate  or  carbolized  solution.     After  this  a  clean 


ASEPTIC  AND  ANTISEPTIC  OPERATING,  ETC. 


711 


set  of  iiiidur-clotliiug  is  donned  h\  tlie  patient,  who  is  now  ready  for 
the  o])eration.  As  a  matter  of  course,  on  the  day  preceding  the  opera- 
tion a  hixative  is  administered. 

In  tlie  mean  time,  tlie  operating-room  is  prepared.  The  instruments 
to  he  used  are  hoiked  and  arranged  in  glass  trays  tiUed  with  a  weak  car- 
bolic solution  (1  or  '1  per  cent.),  which,  like  all  the  other  utensils,  are 
placed  on  glass  tables  previously  spread  with  clean  sheets.  Ligatures, 
sutures,  and  the  thermo-cautery  (its  handle  wrapped  with  sterilized  gauze), 
are  put  conveniently  in  readiness.  Likewise  enamelled  or  glass  basins 
containiugu  1  :  2()t)0  solution  of  corrosive  sublimate,  or,  when  theabdomen 
is  invaded,  boro-salieylic  solution,  are  prepared  for  the  fre(|uent   rinsing 

of  the  surgeon's  hands.  A  suit^ 
able  number  of  sterilized  sponges 
are  thrown  intoaclean  glass  basin, 
alongside  of  which  stands  another 
basin  tilled  with  hot  sterile  water 
lor  rinsing  them  of  l)lood.  The 
dressings  are  arranged  on  another 
table  in  the  closed  receptacles 
within  which  they  were  steamed, 

Fig.  190. 


0|)fmting-liabit  of  surgeon. 


Operating-liabit  of  nurse. 


or,  siioidd  steaming  be  impossible,  are  cut  and  folded  in  the  order  in 
winch  they  are  to  be  apjilicd  to  the  wound,  and  are  then  wrapj)ed  in  a 
clean   towel   ready  for  u.-.e. 


712     THE  TECHNIQUE  OF  ANTISEPTIC  AND  ASEPTIC  SURGERY. 


Before  touchinji^  any  of  tlic  a|)](iirtcnances  of  the  operating-room  the 
surgeons  and  nurses  divest  tiieniseives  of  tiieir  ordinary  wearing  ajiparel, 
Avhich  notoriously  contains  large  (juantitie.s  of  dust  and  dirt,  seruli  and 
disinfect  their  hands  in  the  manner  formerly  described,  and  ilon 
clean,  well-sterilized    operating-gowns    made  of  strong  linen  or  duck 


Fig.  191. 


Fig.  192. 


\ 
V 


/ 


J 


Aseptic  chloroform  mask  of  ScUiimii^  ll.u.-ih. 


(Figs.  189  and  190).       Where  the  operator  has  to  work  in  the  sitting 
posture,  as  in  rectal  and  urethral  operations,  he  wears  a  rubljcr  apron 


underneath  the  linen  gown. 


These  measures  should  all  l)e  carried  out 


Fig.  193. 


Applying  aseptic  cap  (first  step). 


with  due  thoroughness,  but  without  finick-t/  exaggeration.  Finally,  the 
hands  are  once  more  washed  immediately  before  the  beginning  of  the 
operation. 

The  patient  is  now  ana?sthetized.     The  metal  frame  of  the  chloroform 
mask  to  be  used  must  be  previously  boiled,  then  covered  \\ith  sterilized 


ASEPTIC  AND  ANTISEPTIC  OPERATING,  ETC. 


713 


gauze.  Ethei'  nia.<k.s  arc  more  difficult  to  cleanse,  but  they  caa  also  be 
rendered  safe  by  dipping  the  mask  for  ten  minutes  into  hot  soda  solu- 
tion having  a  temperature  just  below  the  boiling-])oint.  The  sponge 
in  Ormsby's  apparatus  ought  to  be  renewed  for  each  separate  an:esthesia. 
The  gags,  tongue-forceps,  sponge-holders  for  wij)ing  out  the  fauces,  the 
hypotlermic  syringe — in  short,  all  the  utensils  of  the  ana^sthetizcr — should 
be  rendered  aseptic  before  use.  During  the  ])rogress  of  the  operation  it 
is  the  duty  of  the  anpesthetizer  to  manage  the  head  of  the  patient  so  as 
not  to  have  vomit  and  s;iliva  contaminate  the  wound. 

As  soon  as  the  ana'sthesia  is  complete  the  hair  of  the  pailcnt  is  freed 
of  hairpins,  is  arranged  on  the  top  of  the  head,  and  is  enveloj)ed  in  a 
cap  made  of  a  towel  wrung  out  ofsul)limate  solution,  which,  again,  is 
secured  by  a  few  turns  of  a  narrow  bandage  (Figs.  193,  194,  195). 

Fig.  194. 


Applying  aseptic  ivip  (second  step). 


Now  the  jjatient  is  placed  on  the  o]ierating-table,  and  the  field  of 
operation,  being  exposed,  is  once  more  subjected  to  a  thorough  scrubl)ing 
with  hot  water  anil  soft  soap,  followed   by  washing  with  ether  and  a 

Fig.  195. 


Aseptic  cap  in  situ. 


1  :  1000  solution  of  corrosive  sublimate.  Only  the  field  of  ojieration  re- 
mains exposed,  .tile  rest  of  the  body  lieing  ]irotecte<l  bv  flannel  leggings, 
blankets,  and  rublier  sheet.s,  which  in  turn  are  coveretl  close  up  to  the 


714     THE  TECHNIQUE  OF  ANTISEPTIC  AND  ASEPTIC  SURGERY. 

limits  of  tho  field  of  openitimi  with  sterilized  towels.  These  prevent 
accidental  contact  witli  non-stcrilizcd  parts  of  the  bodv  of  tiie  j)ati('nt, 
and  enable  the  surgeon  to  rest  his  liand  and  arm  or  to  lav  down  an  in- 
strument witiiont  fear  of  infection. 

Now  the  operation  begins.  Each  assistant  and  atti'nihmt  ought  to 
know  precisely  vvliat  his  duties  are  :  these  ought  to  be  performed  (piickly, 
promptly,  but  without  haste,  in  an  orderly,  systematic  manner,  and  with 
sucli  an  intelligent  steadiness  that  tlieir  constant  and  detailed  sn])ervis- 
ion  and  control  by  tiie  o])erator  ought  to  be  unnecessai'y.  Ks))('cially 
in  unexpected  anil  critical  emergencies  no  panic  shoultl  l)e  tolerated, 
as  this  usually  leads  to  gross  violations  of  aseptic  discipline.  But  in 
this  matter  the  operator  himself  must  lead  by  good  example.  A\'iien- 
ever  it  becomes  necessary  for  any  one  engaged  about  tiie  wound  to  touch 
an  undisinfected  ol)ject,  a  careful  reclcansing  by  soap  and  brusii  and  re- 
disinfection  must  follow.  Especially  important  is  this  rule  if  the  sur- 
geon's fingers  come  in  contact,  accidentally  or  intentionally,  with  sejjtic 
surfaces,  as,  for  instance,  when  a  digital  exploration  of  the  rectum  or  oral 
cavity  is  done  for  this  or  that  purpose.  The  hemorrhage  is  stilled  by  the 
application  of  hsemostatic  forcejis  until  the  breast  and  tlie  axillary  con- 
tents are  removed  ;  then  each  vessel  is  carefully  tied  with  catgut  and  the 
wound  is  filled  with  dry  sterilized  gauze  to  check  cajiillary  oozing.  JVo 
irrif/aiion  whatcrcr  is  employed,  as  it  only  tends  to  irritate  the  tissues. 

The  suturing  of  the  edges  of  the  wound  is  begun  and  carried  down 
from  the  median  angle  toward  tlie  axilla,  into  which  a  drainage-tube  is 
now  inserted  through  a  buttonliole  made  from  the  posterior  aspect  of  the 
latissimns  muscle ;  tlie  gauze  [)acking  is  withdrawn,  leaving  a  perfectly  dry 
wound  ;  and  the  suturing  is  completed  from  end  to  end.  As  soon  as  tiie 
wound  is  closed,  constant  pressure  is  exerted  upon  the  wound-cavity  l^y 
sponges  in  the  hands  of  the  assistants.     The  bloody  towels  used  for  pro- 


Fio.  196. 


Completed  dressing  after  breast-amputation  (Gerster). 


tection  are  removed,  the  patient's  skin  is  cleansed,  and  the  dressings  are 
now  applied  so  as  safely  to  enclose  the  wound,  at  the  same  time  exerting 
a  moderate  degree  of  elastic  pressure.     First  comes,  next  to  the  wound,  a 


ASEPTIC  AXD  AXTISEPTIC  OPERATING,  ETC.  715 

strip  of  sterilized  I'ubber  tissue  protective,  tlien  a  strip  of  iodoform  gauze, 
tiien  a  genenins  padding  of  crumpled  loose  gauze  balls  to  till  up  the 
hollows,  tinally  a  number  of  large  gauze  com2)resses  far  overlapping  the 
edges  of  the  wound  in  all  directions.  Now  projecting  parts,  the  other 
breast  and  axillary  margins  and  the  corresponding  arm,  are  covered  Mith 
strips  of  al)S(irl)ent  cotton  (previously  prepared  in  the  shape  of  roller 
bandages),  and  the  whole  mass  of  dressings  and  the  arm  are  included  in 
as  many  turns  of  a  sterilized  muslin  roller  as  necessary.  The  patient  is 
provided  with  clean  warmed  clothes  and  is  placed  in  bed  (Fig.  I'JG). 

The  endeavor  of  every  well-trained  modern  surgeon  must  lie  to  arrange 
the  wound  at  the  time  of  the  operation  and  while  the  patient  is  under  the 
influence  of  the  aniestiietic  in  such  a  manner,  if  ])(issil)le,  as  to  accomplish 
primary  and  uninterrupted  union  without  any  further  interference.  To 
do  this  a  number  of  indispensable  conditions  must  licfultilled  in  addition 
to  surgical  cleanliness. 

First.  There  must  be  a  very  thorough  attention  paid  to  the  stoppage 
of  hemorrhage.  All  bleeding  points  must  be  secured  by  ligature,  and 
the  use  of  irritating  chemicals  u])on  the  raw  surfaces  must  be  avoided, 
as  it  tends  to  dissolve  thrombi  and  to  cause  profuse  cajiillary  oozing.  It 
is  true  that  a  perfectly  aseptic  wound  ought  to  behave  like  a  sul)cuta- 
neous  injury — for  instance,  like  a  fracture — but  it  is  just  as  true  that 
even  the  most  scrupulous  endeavors  at  asepticism  will  occasionally  fail 
on  aceonnt  of  various  accidental  influences.  Although  we  know  that  a 
really  aseptic,  artiticially-closi'd  wound  may  and  often  does  heal  without 
suppuration,  even  if  it  l)C  disten<lc(l  by  a  massive  blood-clot,  we  know, 
on  the  other  hand,  just  as  well,  that  should  an  however  minute  infection 
have  taken  })lace,  the  microbes  deposited  in  the  blood-clot  \\ould  not 
only  find  a  favorable  pabulum  for  their  development,  but  that  the  direct 
germicidal  effect  of  the  fresh  circulating  blood  and  of  the  living  tissues 
sejiarated  from  the  microbes  by  the  clot  could  not  be  exerted;  hence 
breaking  down  and  su|>puration  would  inevitably  follow.  A  massive 
blood-clot  in  the  wound  is  dangerous  l)ccausc  it  serves  as  a  culture 
medium  to  accidentally-entered  microbes,  and  because  it  jirevents  con- 
tact of  the  living  walls  of  the  wound.  It  must  be  added,  however,  that 
as  we  are  better  able  to  produce  really  aseptic  wonnds,  so  in  propor- 
tion the  danger  from  this  source  is  diminishing.  Were  this  not  so,  then 
a  healing  uiulcr  the  hlood-c/of,  as  observed  in  irregular  hollow  wounds 
treated  according  to  Schede's  method,  would  l)c  an   impossibility. 

The  second  desideratum  in  the  treatment  of  fresh  wounds  is  the 
prevention  of  the  accumulation  and  retention  of  bloody  serum.  This 
also  is  a  good  jiabulmn  for  the  growth  of  micro-organisms  and  tends  to 
separate  the  walls  of  the  woun<l  and  to  create  tension.  To  jirevent  this 
disturbance  we  have' to  estal>lish  ettective  drainage,  especially  in  deep, 
sinuous  wounds  and  in  those  the  walls  of  which  cannot  l)e  kcjit  in  actual 
contact  by  external  pressure  or  by  buried  sutures.  Whether  the  means 
of  drainage  should  be  a  gauze  wick  or  a  drainage-tube,  or  merely  the 
leaving  open  of  an  angle  of  the  wound,  or  sparingly-employed  sutures, 
— this  nmst  be  left  to  the  skill  and  judgment  of  the  surgeon.  The 
selection  of  the  site  of  the  drainage  is  also  an  important  one,  a  dependent 
situation  being  preferable.  (Jood  ilraiuage  will  keep  the  wound  dry  and 
empty — will  permit  its  walls  to  remain  in  close  contact.     It  will  prevent 


71  <i     THE  TECHNIQUE  OF  ANTISEPTIC  AND  ASEPTIC  SURGERY. 

tho  retention  of  fluids  ]iroiic  to  serve  as  a  hotbed  for  tiie  propagation 
of  noxious  ijcrnis.  ]5ut  iiere,  as  in  regard  to  h»mostasis,  it  may  be 
saiil  tliat  tile  more  perfect  tiie  surgeon's  aseptic  slvill,  tlie  wider  will 
beeome  the  margin  of  cases  in  which  lie  can  dispense  with  formal 
drainage. 

The  third  requirement  is  not  to  tear  and  bruise  the  wound-surfaces. 
The  rough  handling  due  to  inadecpiate  external  incisions  and  the 
so-called  blind  methods  of  preparailou  necessarily  damage  the  tissues 
much  more  tlian  the  clean  and  easy  stroke  of  a  sharp  knife.  The 
slightest  infection  carried  into  such  damaged  tissues  must  result  in  their 
destruction  by  supjniration,  while  it  might  have  been  overcome  by  the 
undiminished  energy  of  the  circulation  of  viable  tissues.  But  even  this 
generally  sound  rule  admits  of  exceptions,  as  we  know  that  a  perfectly 
aseptic  wound  will  tolerate  and  permit  not  only  encapsulation  of  dead 
organic  substances,  but  also  of  inorganic  material.  As  a  proof  of  this 
statement  may  serve  the  behavior  of  the  average  buried  pedicle  cut 
ofi'  from  circulation  by  a  ligature. 

A  fourth  requirement  is  intimate  contact  not  only  of  the  edges  of  the 
external  wound,  but  of  all  the  inner  surfaces.  Superficial  and  deep-buried 
sutures  and  external  elastic  jircssure  liy  suitable  bandaging  of  the  dress- 
ings must  accomplisli  this.  Perfect  rest  of  the  wound  in  the  condition 
created  by  the  surgeon  must  be  further  secured  by  splints  and  otlier 
means  of  fixation  according  to  necessity. 

The  last  condition  of  success  is  the  prevention  of  any  interference 
with  the  circulation  of  the  parts  bordering  the  wound  by  too  tight 
bandaging,  false  position,  or  other  influences. 

Where  all  of  these  ccmditions  can  be  fulfilled  without  the  necessity  of 
leaving  in  the  wound  any  foreign  unalisorbable  substance,  the  ideal  of 
modern  ^vound-treatment — that  is,  hca/ine/  under  one  dressing — will  be 
the  gratifying  result.  And  it  affords  the  surgeon  much  pleasure  to 
observe  that  the  limits  of  this  ideal  treatment  are  being  safely  and 
steadily  widened  all  the  time. 

When  Neuber  first  advanced  the  jirinciples  of  strongly  absorlicnt 
exsiccating  dressings,  which  were  to  hv  left  undisturbed  until  the  wound 
was  healed,  many  surgeons  were  unwilling  to  try  the  new  metliod,  fear- 
ing to  forego  the  precaution  of  inspecting  the  wound  at  frequent  inter\als. 
But  the  great  safety  of  Neuber's  "  ]iermanent  dressing  "  (Dauerverband) 
has  been  abundantly  jiroven.  It  is  universally  accepted  now,  and  we 
have  learned  to  estimate  with  great  accuracy  the  exact  condition  of  a 
wound  witliout  actual  inspection.  From  this  new  experience  was  dra^^■n 
the  fundamental  rule  of  never  disturbing  a  dressing  without  a  clear  and 
urgent  indication.  Let  us  first  see  what  is  the  course  of  events  Avlien  a 
wound  heals  without  disturl^ance  of  the  natural  process.  Immediately 
following  the  operation  there  will  be  some  restlessness,  nausea,  even 
vomiting,  due  to  the  anttsthetic,  and  later  on  com])laints  of  pain,  which 
will  need  some  attention.  But  on  the  day  following  the  patient  will 
comj)lnin  much  less,  and  his  general  aspect  will  be  a  favorable  one.  The 
temperature,  often  subnormal  directly  after  the  operation,  will  have  risen 
somewhat,  occasionally  even  as  high  as  103°  F.,  but  the  jjatient's  general 
condition  and  morale  do  not  jiroelaim  him  to  be  sick.  The  assumption 
that  every  asejjtic  operation  ought  to  be  followed  by  a  feverless  process 


ASEPTIC  ANB  ANTISEPTIC  OPEBATING,  ETC.  717 

of  healing  is  misleading,  and  docs  not  correspond  with  ai-tual  facts 
ackn(i\vk'tlgo(l  hy  honest  observers.  Almost  every  subeutaneons,  hence 
perfectly  aseptic,  fracture  is  tbllowed  by  some  fever,  which  occasionally 
rises  as  high  as  105°  F.  Volkmann  made  carefnlly-reet)rded  observa- 
tions on  a  series  of  fourteen  subcutaneous  fractures  of  the  thigh. 
Eleven  of  these  had  fever,  three  had  none.  Mostly  the  fever  continued 
for  three  or  four  days,  with  elevations  of  the  temperature  to  fmni  103° 
to  10.j°  F.  Two  patients  were  feverish  for  ten  days,  one  for  eleven, 
another  one  for  sixteen  days.  But  all  of  these  jiaticnts,  tiiough  their 
faces  were  flushed,  were  not  ill  in  the  least ;  they  \\ere  simply  going 
through  an  aseptic  fever  due  to  the  absorption  and  elimination  of  the 
Jibrln-fermenf  furnished  by  the  extensive  blood-clot  surrounding  the 
place  of  fracture.  This  fever  interferes  in  a  very  slight  degree,  if  at  all, 
with  the  well-being  of  the  ]iatit'nt ;  it  generally  begins  almost  iminiiU'ife/i/ 
after  the  (ipi'ration,  and  gradually  subsides  into  a  normal  state  of  health. 
Volkmann  was  not  far  from  the  truth  when  he  stated  that  about  one- 
third  of  all  patients  treated  successfully  according  to  the  aseptic  plan 
\\ere  feverless,  one-third  had  moderate  fever,  and  the  last  third  higli 
fever. 

When  moderate  or  even  high  fever  is  observed,  beginning  slowly 
after  an  oiK'ration,  but  not  accompanied  by  severe  disturlxuice  of  the 
general  well-being,  when  at  the  same  time  the  pain  in  the  wound  is 
clearly  diminishing  and  the  pertinent  lymphatiG  glands  do  not  become 
tender  to  touch,  the  surgeon  is  justified  in  assuming  that  the  wound  is 
doing  well  and  the  dressings  need  not  be  disturbed. 

When,  on  the  otiier  hand,  the  fever  is  due  to  septic  infection,  it  gen- 
erally sets  in  on  the  second  or  third  day.  While  absorption  of  the 
fibrin-ferment  begins  immediately  following  the  formation  of  clot,  the 
proliferation  of  septic  germs  must  reach  a  certain  extent  before  they  can 
provoke  any  serious  systemic  disturbance.  Therefore,  whenever  an  infec- 
tion of  the  wound  has  taken  place,  tlie  septic  fever,  usually  ushered  in  by 
a  rigor  and  followed  l)y  tlie  well-known  appearances  of  general  intoxica- 
tion and  local  inflammation,  rarely  sets  in  before  the  third  day.  A\'Iii]e 
aseptic  i'ever  generally  subsides  l)y  the  fourth  day,  septic  fever  continues 
until  a  healthy  condition  of  the  wound  is  established. 

A  change  of  dressings  should  take  place  under  the  following  indica- 
tions only  : 

1.  If  the  dressings  appear  to  be  thoroughly  soaked  with  disciiarges  ; 

2.  M^henever  it  becomes  necessary  to  remove  drainage-tubes  and 
stitches  ; 

3.  Immediately  when  a  well-grounded  suspicion  arises  that  the 
wound  has  been  infected. 

^'ery  often,  after-  a  large  operation,  especially  when  Esmarch's 
bandage  has  l)een  used,  a  Ihnited  area  of  the  dressings  becomes  per- 
meated with  blood  or  bloody  serum.  This  does  n(jt  necessitate  a  cjiange. 
It  will  be  sutficient  under  these  circumstances  to  dust  the  soiled  spot  with 
iodoform  and  to  bandage  one  or  more  clean  compresses  of  absorbent 
gauze  over  it.  Should  the  entire  dressing  become  wet  with  bloody 
serum,  only  the  superficial  dressings  need  be  changed.  The  iodoform 
compress  which  forms  the  inmicdiate  covering  of  the  wound  ought  not 
to  be  disturbed  under  these  circumstances. 


71.S     THE  TECHNIQUE  OF  ANTISEPTIC  AND  ASEPTIC  SURGERY. 

Sliould  the  dressiiijrs  become  soiled  from  witliout,  especially  by  faeces 
and   iii'inc,  a  chanj^c  will  be  indisjiensable. 

Silk  sutures  and  rubber  drainanc-tubes  are  foreign  bodies  tliat  must 
be  witlidrawii  as  soon  as  their  ofHee  is  fultillcd.  The  oo/.ing  of 
bloody  st'rum  from  an  aseptic  wound  has  generally  ceased  after  seventy- 
six  hours,  and  the  agglutination  of  the  sutured  edges  of  a  healthy 
wound  is  by  this  time  also  secured.  But  as  the  vital  processes  are 
somewhat  slower  in  some  than  in  other  persons,  it  will  be  safest  to 
remove  both  sutures  and  drainage-tubes  by  the  fourth  day.  When  on 
inspection  the  wound  is  found  normal,  the  tube  ought  to  be  withdrawn 
at  once  and  for  good.  When  a  clean  and  iirm  blood-clot  is  found 
occupying  the  hollow  of  the  witiidrawn  tube,  this  gives  a  safe  assurance 
of  the  asepticity  of  the  wound,  which  does  not  need  any  further  diain- 
age.  Should  there  be  any  doubt  on  this  point,  however,  then  it  will  be 
wiser  to  re])lace  the  tube  until  the  doubt  is  dispersed.  The  idea  that 
tiihcx  irritate  wounds  is  entire/j/  fa/lacions :  tubes  become  irritant  only 
when  pvogenetic  germs  are  carried  In'  them  into  the  wound,  which  may 
occur  when  they  are  replaced  after  having  been  infecteil  outside  of  the 
wound  by  contact  with  filth.  If  things  prosper,  a  drained  wound 
may  be  entirely  healed  under  two  or  three  dressings. 

This  normal  proceeding  and  course  of  healing  is  the  nde  in  the 
majority  of  wounds  caused  by  the  surgeon.  It  will  be  proper  to  devote 
a  few  remarks  to  the  exce})tions. 

Occasionally  tissues  are  invaded  which  are  very  vascular,  and  from 
which,  though  the  larger  vessels  were  all  secured,  a  profuse  capillary 
<iozing  will  continue  for  a  long  time.  To  check  this  oozing  the  surgeon 
must  resort  to  packing.  Or,  to  take  another  example,  a  large  vein  is 
accidentally  injured  in  a  place  where  the  application  of  a  ligature  is 
impossible,  as,  for  instance,  about  the  intracranial  sinuses.  Here  also 
packing  is  the  only  remedy. 

In  the  first  case,  where  cessation  of  capillary  oozing  only  has  to  be 
waited  for,  the  packings  can  be  withdrawn  in  forty-eight  hours.  The 
wound  will  be  found  dry,  and  just  as  fresh  as  it  was  before  packing. 
It  can  be  treated  as  a  fresh  wound — that  is,  sutures  are  to  be  a]i])lied — 
and  in  most  cases  it  will  behave  like  a  fresh  wound  and  will  heal  by 
primary  adhesion.  After  excisions  of  a  joint,  esjiecially  that  of  the 
hip,  operations  for  vascular  tumors,  and  some  amjjutations,  this  form 
of  treatment  will  yield  excellent  results. 

When  a  large  venous  trunk  has  to  be  occluded  by  packing,  it  \\  ill 
not  be  safe  to  disturb  the  plug  Ix'fore  either  a  solid  thrombus  has  formed 
or  adhesion  of  the  cumjiressed  walls  of  the  injured  vessel  has  taken  place. 
This  will  rarely  hap]H'n  in  less  than  a  week,  after  the  lapse  of  which  tiie 
plug  will  become  loosened  and  can  be  removed  without  fear. 

In  operations  about  the  oral  cavity,  pharynx,  and  larynx,  as  well  as 
the  rectum,  contact  of  the  natural  discharges  with  the  wound-surface 
will  lead  unavoidably  to  infection  and  serious  mischief.  This  contact 
cannot  ever  be  absolutely  jirevented,  but  it  can  be  materially  modified  as 
to  its  cf)nsequenccs  Injudicious  jiacking.  We  see  after  an  excision  of 
the  jaw  or  tongue,  for  instance,  that  a  properly-])lugiied  wound  does  not 
become  infected,  inflamed,  and  fetid,  though  the  tampons  are  more  or 
less  soaked  with  saliva,  blood,  or  vomit  for  a  week  or  ten  days. 


ANTISEPTIC  METHODS.  719 

Finally,  it  is  necessary  to  mention  another  class  of  wounds  in  which 
treatment  In-  packing  yields  excellent  results.  Tiiese  arc  wounds  the 
asaptkity  (if  irli'u-h  in  (i  maffcr  of  doubt ;  for  instance,  the  wound  after 
excision  of  suppurating  lymphatic  glands  or  a  suppurating  tuberculous 
joint.  Here  the  surgeon  would  run  great  risk  by  closing  the  wound. 
Temporary  jjacking  will  be  much  safer,  as  it  affords  excellent  and  most 
aljundant  capillary  drainage,  by  which  all  infectious  material  that  might 
be  lingering  in  the  wound  is  carried  away,  and  the  i)lugs  themselves  exert 
an  antiseptic  action. 

Prolonged  piickiii;/  without  detriment  to  the  wound  Ijccame  a  recog- 
nized method  only  after  the  wonderful  (pialities  of  iodoform  were  clearly 
understood  and  appreciated,  ^\'hatever  the  chemism  may  be  by  which 
iodoform  develops  its  antiseptic  properties,  no  .surgeon  of  this  day  has 
any  doubts  about  them.  By  the  aid  of  iodoformed  tanij)ons  severe  hem- 
orrhage can  lie  safely  controlled  witiiout  conniromising  our  chances  for 
the  hi'aling  of  tiic  wound  by  primary  adhesion  ;  and,  finally,  wounds  of 
doubtful  asej)ticity  can  be  rescued  l)y  the  same  process  from  suppuration. 

By  mentioning  this  last  contingency  Ave  have  trenched  on  the  field  of 
anflsejific  technique,  which  must  now  engage  our  attention.  Wherein 
lies  the  difference  between  aseptic  and  antiseptic  management? 

Axepsifs  is  the  teciniique  by  which  a  primarily  clean  and  germ-free 
wound  is  maintained  in  its  original  condition  ;  untifsepxix,  on  the  other 
hand,  is  the  procedure  the  object  of  which  is  the  destruction  and  elimi- 
nation of  noxious  germs  that  have  found  lodgement  in  the  human  tissues 
and  are  damaging  them. 

Let  us  now  I'xamine  the  agencies  by  M"hich  a  sejitic  or  infectious 
process  established  in  the  human  tissues  can  be  .stopped.  The  agencies 
that  can  come  in  question  are — 

1.  Thermic  ; 

2.  Chemical  ; 
•3.  Mechanical. 

The  power  of  the  actual  cautery  to  stop  various  forms  of  progressive 
ulceration  is  a  fiu^t  known  to  the  oldest  surgical  A\riters.  It  is  based  upon 
tlie  destruction  of  all  or  most  of  the  pathogenetic  germs  causing  the 
ulceration,  together  with  the  tissues  within  whii'h  they  have  proliferateil. 
Tissues  and  germs  are  converted  into  a  dry  eschar,  which  remains  for 
some  time  an  unfavorable  breeding-place  for  any  germs  that  might  have 
escaped  destruction  by  the  red  heat.  Chancres,  lupoid  and  tuberculous 
ulcers,  even  hospital  gangrene,  are  all  amenable  to  the  action  of  tiie 
actual  cautery.  The  field  of  its  application  is  limited,  but  where  it  can 
be  employed  it  is  very  trustworthy  and  entirely  safe. 

Chemical  means  of  absolutely  sto])ping  a  progressive  septic  process 
must  be  employed  in  such  a  manner  as  to  imitate  the  action  of  the  actual 
cautery.  Weak  solutions  will  certainly  lave  and  cleanse,  even  disinfect 
to  a  limited  extent,  the  xurfiee  of  an  inflamed  septic^  area,  but  the  deeper 
and  deepest  portions  of  the  infected  mass  of  tissues  will  not,  and  cannot, 
be  influenced  in  tiie  least  by  a  weak  apjilication,  temporary  or  even  ])er- 
manent.  To  influence  a  carbuncle,  for  instance,  a  mild  external  applica- 
tion of  any  disinfectant  will  be  utterly  useless.  Infection  of  new  ai-eas 
and  necrosis  of  tiie  affected  tissues  will  go  on  througii  the  entire  thickness 
of  tiie  diseased  skin.     To  stop  the  process  in  its  inception  by  chemical 


720     THE  TECHNIQUE  OF  ANTISEPTIC  AND  ASEPTIC  SURGERY. 

influences  the  entire  area  of  infected  tismies  viuM  be  destroyed  or  comwrted 
into  a  dry  enchur.  So,  for  instance,  the  s])read  of  a  carbuncle  can  be 
.stoj^pcd  very  promptly  by  the  corrosion  of  the  incipient  focus  throughout 
its  whole  extent  and  depth  with  dry  bichloride  of  mercury,  or  a  paste  of 
chloride  of  zinc,  or  by  chromic  acid  or  nitric  acid.  Just  as  the  actual 
cautery,  so  these  chemicals,  to  be  etifcctive  must  include  in  their  grasp 
ev<'rything  that  is  diseased.  Hhoitid  a  portion  e>J'  the  infected  area  not  be 
included  in  the  eschar,  the  disease  'will  continue  to  advance.  Where  the 
escharotic  has  destroyed  all  of  the  infected  mass  the  fever  and  the 
local  irritation  will  diminish  or  cease  at  once. 

Where  very  extended  areas  are  involved  tlie  ;t]>])licati(in  of  chemical 
escharotics  is  forbidden  on  account  of  their  poisonous  t'tl'ect. 

AYe  have  seen  that  escharotics,  however  reliable  and  excellent,  admit 
only  of  a  limited  application  ;  further,  we  have  shown  in  former  sections 
of  this  paper  that  the  influence  of  weaker  solutions  of  the  useful  germi- 
cides is  very  superficial,  non-penetrating,  and  is  furthermore  restricted 
by  the  danger  of  poisoning  by  absorption.  Let  us  now  examine  what 
further  means  the  surgeon  possesses  for  the  elimination  of  septic  material 
from  the  tissues  of  the  human  body. 

Here,  as  well  as  in  the  practice  of  asepsis,  mechanical  measures  are 
of  the  first  and,  utmost  importance.  By  mechanical  measures  we  under- 
stand— 

1.  Incisions. — Tlieir  object  is  first  to  relieve  tension.  To  do  this  they 
must  be  very  ample  and  free,  and  should  penetrate  that  layer  of  tissues 
beneath  which  is  situated  the  cause  of  tension.  In  osteomyelitis  the 
periosteum  and  cortical  layer  of  the  affected  bone  must  be  laid  open  to 
relieve  tension  ;  in  subfascial  phlegmon  the  fascia,  in  glandular  phlegmon 
the  glandular  capsule,  must  be  freely  split  to  give  relief.  Very  often  in 
tlie  most  malignant  forms  of  deep-seated  phlegmonous  inflammation 
free  and  deep  incisions  for  the  relief  of  tension  are  urgently  indicated 
very  long  before  any  defined  abscess  and  fiuctuation  could  develop.  To 
wait  for  fluctuation  in  these  cases  means  simply  a  sacrifice  of  the  patient. 
If  an  early  and  ample  incision  is  made  in  a  bad  case  of  deep-seated 
phlegmon — for  instance,  in  Ludwig's  angina — the  knife  will  divide  a 
nearly  bloodless,  recently  necrosed,  intensely  foetid  and  septic  mass  of 
indurated  tissue,  from  which  no  pus,  only  a  limited  quantity  of  ichor, 
will  escape. 

The  second  object  of  incisions  is  the  evaeuedioit  of  li(]uid,  semi-liquid, 
and  solid  products  of  suppuration.  More  or  less  thickened  pus,  shreddy 
and  often  considerable  masses  of  necrosed  fascia,  must  be  evacuated. 
To  aid  the  first  evacuation  of  abscesses  irric/ation  of  the  cavity  may  be 
employed.  As  the  mechanical  effect  of  the  irrigating  stream  is  the  one 
we  want,  its  chemical  effect  being  insignificant,  irrigation  nuist  be  based 
on  correct  hydrostatics,  which  will  enable  a  stron;/  current  of  solution  or 
plain  boiled  water  to  sweep  through  the  cavity,  carrying  with  it  all  the 
pus  and  detritus.  Two  incisions  (counter-incision),  or,  where  only  one 
incision  is  feasil)le,  the  introduction  of  two  parallel  drainage-tubes,  one 
used  for  the  influx,  the  other  for  the  outflow  of  the  irrigating  fluid,  will 
be  more  efficient  tiian  one  single  tube.  Irrigation  tIiroit(/h  a  single  tube 
ought  to  be  done  cuutiou,4y,  so  as  not  to  cause  over-disfeidion  and  rupture 
of  the  walls  of  the  abscess-cavity — a  warning  especially  to  be  heeded  in 


ACCIDENTAL   WOUNDS  AND  EMERGENCY  DRESSINGS.       721 

abscesses  near  tlic  peritoneum  and  pleura.  Evacuation  of  an  abscess 
should  never  be  aided  by  squeezing  and  pressure,  as  they  are  barbarous 
and  might  lead  to  further  and  serious  infection. 

Drainage  of  abscess-cavities  through  incisions  by  means  of  rubber  or 
glass  tubes  or  a  gauze  packing  /.s  imporfanf,  and  h  indicated  as  long  as 
the  u-alls  of  the  earlfi/  continne  to  slicd  effete  or  dead  material.  The  tubes 
should  be  ample  and  should  occupy  the  most  dcixMideut  position,  so  as 
to  carry  away  the  discharges  by  the  aid  of  the  force  of  gi'avity  by  the 
shortest  and  most  direct  route.  They  must  be  placed  so  as  not  to  be 
liable  to  be  expelled,  and  should  not  impinge  on  nerves  or  vessels. 
Their  daily  cleansing  and  revision — to  extract  large  masses  of  sloughing 
tissues,  for  instance — are  imperative.  Likewise,  insjji-^sation  by  evap- 
oration at  their  external  orifices  must  be  prevented  bi/  means  of  moist 
dressings,  otherwise  retention  might  ensue  in  sjiite  of  drainage. 

As  soon  as  the  discharges  become  serous  and  limpid  the  cleansing  of 
the  cavity  is  finished,  and  the  drainage-tubes  should  be  removed. 

Drainage  bij  packing,  usually  with  iodoform  gauze,  is  indicated 
where  the  whoif  extent  of  an  infecte<l  cavity  must  bi'  kept  patulous  for 
some  time.  Where  and  how  long  this  has  to  be  done  cannot  be  dis- 
cussed here,  and  must  l)e  looked  up  elsewhere. 

A  very  important  aid  to  drainage  is  posture  of  the  body  or  a  limb, 
by  which  not  only  the  efflux  of  discharges  may  be  facilitated,  but  also 
impediments  to  the  circulation  may  be  counteracted  or  even  eliminated. 

A  well-drained  wound  does  not  need  either  squeezing  or  irrigation. 
Where  proper  drainage  is  impossible  for  anatomical  reasons,  irrigation, 
occasionally  frc(pient,  sometimes  even  permanent,  must  make  u|)  for  the 
defective  drainage.  Xon-poisonous  substances,  as  salicylic  acid  or  ace- 
tate of  alumina,  are  the  only  ones  that  ought  to  be  used  for  this  purpose. 

As  long  as  the  cleansing  of  an  incised  and  drained  focus  has  not  been 
manifested  In'  the  cessation  of  fever,  pain,  and  the  final  change  of  the 
discharge  from  ichorous  and  purulent  to  a  bland,  scanty,  and  serous  one, 
the  dressings  should  Ix'  moist  and  need  frequent  changing.  As  soon  as 
the  cavity  is  cleaned  and  the  drainage-tubes  are  withdrawn  a  dry,  evap- 
orating dressing  ought  to  be  applied,  and  this  should  be  left  on  for  a 
considerable  time,  often  to  the  very  healing  of  the  wound. 

Xn.  Accidental  Wounds  and  Emergency  Dressings. 

In  dealing  with  accidental  wounds  our  first  endeavor  must  be  not  to 
inflict  additional  damage  by  ill-considered  and  hasty  attempts  at  relief. 
Ex])erience  has  shown  abundantly  that  a  vast  projiortion  of  all  acci- 
dental wounds  are  aseptic,  and  if  managed  pro)X'rly  will  heal  kindly  and 
without  untoward  con>i>lications.  TJicrcfore,  all  forms  of  first  aid  given 
to  the  wounded  nuist  he  of  ^ucli  a  character  as  not  to  compromise  the 
possibly  aseptic  character  of  tlie  injury. 

HastLi  and  unprepared  e.rji/oratlons  by  finger  or  probe  are  abso/ute/i/ 
reprehensible  and  useless,  as  their  ordinary  consequence  is  an  infection 
of  the  deeper  parts  of  the  wound. 

The  efforts  of  the  surgeon  sliould  be  directed  toward  a  protection  of 
the  wound  bv  an  aseptic  dressing,  which,  n]i]ili<'d  with  a  niodcrato 
amount  of  pressure,  will  sufiice  to  check  ordinary  liemorrliage.     Siiould 

Vol.  I.— 46 


722     THE  TECHNIQUE  OF  ANTISEPTIC  AND  ASEPTIC  SURGERY. 

hemorrhage  be  profuse  on  account  of  injury  to  a  large  vessel,  jiroximal 
or  distal  compression  by  an  exteni])orized  tourniquet  made  of  an  elastic 
suspender,  or  by  a  iSjnmisli  windlass  (Fig.  197),  will  be  sufficient  to  fulfil 

Fig.  197. 


Spanish  windlass. 


the  immediate  requirements  for  hiemostasis  until  the  transfer  of  the 
patient  to  his  home  or  to  a  hospital  is  completed.  Should  a  fracture  be 
jjresent,  the  application  of  a  splint  in  addition  to  the  occlusive  dressing 
is  all  that  is  required. 

Injury  of  the  large  vessels  of  the  neck  or  groin,  requiring  imme- 
diate pressure  by  the  tinger-tip  in  the  bottom  of  the  wound,  is  extremely 
rare.  Here,  of  course,  we  have  no  choice,  as  time  is  precious  and  a  few 
minutes  of  unchecked  hemorrhage  may  result  in  the  patient's  death. 
But  this  class  of  cases  is  the  only  one  where  the  introduction  of  an 
uncleansed  finger  might  be  pardonable. 

Washing  or  rinsing  of  an  accidental  wound  with  styptics,  caustic 
solutions,  vinegar,  arnica,  or  even  the  polluted  water  of  a  well,  spring, 
river,  or  canal,  is  also  injudicious,  as  it  is  useless  and  may  carry  infection 
into  the  wound.  The  wisest  thing  to  dt)  is  to  wipe  away  the  blood  and 
dirt  from  the  vicinity  of  the  wound,  which  ought  theu  to  he  covered 
with  a  clean,  newly-washed,  and  ironed  cloth,  fastened  down  with  a  few 
turns  of  roller  bandage  or  hrmly  tied  on  with  a  handkerchief.  If  time 
and  cii'cumstances  permit,  sterilized  or  iodoformed  gauze  should  be  pro- 
cured for  this  first  dressing. 

As  soon  as  the  patient  is  in  his  home  or  in  a  hospital,  the  permanent 
disposal  of  the  indications  arising  from  the  injury  will  be  iu  order.  The 
parts  will  have  to  be  prejiared  as  for  any  operation  according  to  tlie 
priuci])les  described  in  the  preceding  sections,  and  then  the  necessary 
operative  steps  can  be  safely  taken. 

Small  penetrating  Avounds  of  the  extremities,  caused  by  penetration 


BEGIONAL  TECHNIQUE.  723 

of  fractured  bones  or  by  gunshot,  unless  arterial  hemorrhage  demand 
Inral  or  proximal  deligation,  will  not  need  anything  but  thorough 
eleansing  of  the  neighl)orhood  of  the  wound,  together  witii  an  occlusive 
aseptic  dressing. 

Large  lacerated  and  contused  wounds,  much  soiled  by  contact  with 
street-dirt,  will  require  careful  cleansing  after  complete  exposure  of  all 
soiled  recesses,  followed  by  drainage  and  a  suitable  dressing,  with  or 
without  fixation. 

Under  the  application  of  these  principles  the  results  achieved  by  the 
surgeon  in  cases  of  compound  fracture  and  of  gunshot  injury  are 
excellent. 

Xm.  Regional  Technique. 

The  general  rules  governing  aseptic  and  antisejitic  practice  everv- 
where  must  be  somewhat  supplemented  whenever  certain  special  regions 
are  invaded. 

The  careful  dismfcction  of  the  oral  caviti/  is  a  most  important 
preparation  for  all  operations  to  be  done  in  the  mouth  and  the  adjoin- 
ing hollow  spaces.  A  foul  set  of  teeth,  accompanied  bv  acute  or  chronic 
gingivitis,  an  ichorous  discharge  caused  by  necrosis — syphilitic  or  other 
— of  the  nasal,  maxillary,  or  palatal  liones,  are  serious  counter-indica- 
tions to  any  operation  not  imperatively  needed.  The  extraction  of 
decaying  teeth  or  of  sequestra,  the  curing  of  acute  or  chronic  stomatitis 
or  rhinitis,  ought  to  precede  every  important  operation  to  be  performed 
in  the  mouth  or  nose.  Cleansing  of  the  teeth  by  tooth-brush  and  todtli- 
powder — in  short,  a  careful  oral  toilette — is  here  indispensable.  In  some 
cases  of  excessively  neglected  oral  hygiene  it  will  be  even  necessary  to 
subject  the  patient  to  a  systematic  jireliminary  treatment  before  attempt- 
ing an  operation  the  success  of  which  depends  on  a  faultless  primary 
union  ;  as,  for  instance,  uranoplasty  and  staphylorrhaphy. 

The  after-treatment  of  many  oral  operations  has  been  robbed  of  most 
of  its  terrors  by  the  employment  of  tiie  permanent  iodoform  ijauze  pack. 
This,  though  ])ermeated  with  tlie  discharges,  will  protect  the  wound  most 
effectively  against  septic  infection.  It  should  be  left  undisturl)cd  until 
it  becomes  loosened  by  the  granulations,  when  usually  the  dangers  of 
infection  are  overcome.  It  is  remarkable  how  closely  an  iodoform  gauze 
dressing  will  cling  to  the  wound-surface.  To  pull  it  away  before  it  is 
S'jiontaneously  loosened  will  not  only  cause  considerable  jiain,  often  also 
hemorrhage,  but  will  especially  expose  the  fresii  wound  to  septic  influ- 
ences, which  afterward  are  very  hard  to  combat. 

The  cavities  of  the  human  body, — namely,  the  mibaraehnoidal  space, 
pleura,  peritoneum,  and  the  large  joints — also  require  special  care,  as 
their  infection  is  followed  by  most  serious,  often  fatal,  consequences. 

A\  hen  the  .*/.•*///  is  to  be  opened,  xharine/  of  the  entire  head  is  absolutely 
indisjiensable.  In  aildition  to  this  the  scalp  should  be  well  scrubbed, 
and  tiicn  enclosed  in  a  wet  paeiv,  which  has  to  remain  in  sitii  until  the 
patient  is  anaisthetized.  After  the  removal  of  the  wet  pack  the  head 
is  once  more  scrubbed  with  soap  and  water  to  get  rid  of  all  loose  ejiidcr- 
mis.  Where  a  cerebral  ahucesa  is  looked  for,  the  exposed  brain  should 
be  well  protected  by  an  iodoform  gauze  dam  before  the  abscess  is  incised. 
After  the  incision  of  the  abscess  all  shreds  of  pus  must  be  carefully 


724     THE  TECHNIQUE  OF  ANTISEPTIC  AND  ASEPTIC  SURGERY. 

washed  away  with  a  strong  jet  of  irrigating  fluid — a  wealv   sublimate 
sohition — before  the  paclvings  are  removed. 

Whenever  the  jj/cura  nr  the  pcrifoneum  is  acckleufa/lj/  injured 
during  tlie  progress  of  an  o])eration  it  is  good  praetiee  to  paeii  an 
iddoiorm  gauze  eomjiress  into  tiie  rent,  to  be  h'ft  tiiere  until  it  can  be 
closed  by  suture,  or,  if  this  be  impossible,  for  a  longer  ])erio(l  of  time. 
This  packing  will  not  only  protect  the  serous  surfaces  against  infection, 
but  in  the  peritoneal  cavity  M'ill  also  prevent  prolapse  of  intestine. 

Whenever  accidental  soiling  by  the  escape  of  pus  or  cystic  fluid  or 
fseces  is  to  be  feared,  ihc  Jicid  of  operation  our/ht  to  be  effectirely  walled 
off  from  the  red  of  the  peritoneal  or  pleural  cariti/  Iji/  a  ra reftdl tj-con- 
strueted  dam  of  iodoform  (jauze.  Many  intestinal  operations  can  be 
done  entirely  outside  of  the  abdominal  cavity,  for  which  purpose  it  is 
advisable  to  withdraw  from  the  belly  the  jiortion  of  gut  to  be  ope- 
rated on,  if  such  a  step  be  feasible. 

All  ojierations  upon  the  intestine  should  be  ])receded,  if  possible,  by 
a  careful  preparation.  Systematic  laxation  witli  tiie  administration  of 
lifpiid  food  should  cleanse  and  leave  the  bowel  comparatively  empty. 
The  stomach  will  need  siphoning  and  washing  \\henc\'cr  fecal  vomit 
exists  in  cases  of  intestinal  obstruction.  Likewise  will  gastro-enterostomy 
or  pylorectomy  need  a  preliminary  careful  toilette  of  the  stomach. 
Lavage  is  best  done  with  a  (iilOOO  salt  solution. 

During  intestinal  operations  involving  enterorriiaphv  the  greatest 
care  must  be  exercised  to  prevent  soiling  of  the  held  of  operation  by 
fasces.  The  intestinal  coil  to  be  operated  on  is  stripped  of  its  fecal  con- 
tents by  finger  pressure  ;  two  ligatures — one  proximal,  one  distal — are 
applied  to  prevent  the  escape  of  faeces,  and  the  fecal  matter  still  con- 
tained in  tlie  immediate  vicinity  of  the  intestinal  wound  is  wiped  away 
by  sponges  or  pads  of  dry  gauze,  or,  when  the  intestine  can  be  with- 
drawn from  the  belly,  is  thoroughly  flushed  away  in  addition  to  wiping. 
Strong  germicides  are  not  to  be  used,  as  this  might  lead  to  poisoning, 
and  the  main  reliance  is  to  be  placed  here  too  upon  mechanical  instead 
of  chemical  processes  of  cleansing. 

Similar  are  the  measures  of  cleansing  employed  about  the  rectum  and 
anu><.  Thorough  evacuation,  if  possible,  done  lioth  by  laxatives  and  by 
enemata,  is  to  precede  all  important  rectal  oj)erations.  M'iiere  tight 
strictui'e  prevents  a  thorough  emptying  of  the  gut,  inguinal  colotomy 
must  o])en  the  way  to  thorough  purgation.  Immediately  precetling  the 
operation  a  large  sponge  attached  to  a  stout  thread  is  thrust  high  up  into 
the  bowel,  the  distal  part  of  which  is  now  well  swabbed  and  douched 
either  with  Thiersch's  solution  or  with  plain  boiled  water. 

Where  a  rectal  or  anal  wound  cannot  be  closed  by  suture  the  iodo- 
form pack  will  render  most  valuable  service  in  protecting  the  raw  sur- 
faces against  infectious  contact  with  fseces  and  urine. 

The  genito-urinary  tract  is  very  often  infected  by  uncleanly  catheters 
and  bougies,  the  care  and  management  of  which  demand  some  con- 
sideration. 

Urine  secreted  by  healthy  kidneys  and  as  contained  in  the  healtliy 
l)ladder  is  always  free  from  micro-organisms  of  any  kind  (Cazeneuvc  and 
Livon).  On  the  other  hand,  the  decomposition  of  urine,  with  the  sub- 
sequent inflammation  of  the  mucous  lining  of  the  bladder,  is  always  the 


REGIONAL   TECHNIQUE.  725 

direct  consequence  of  tlie  iiitrodiiction  of  certain  microbes  into  the  vis- 
cus,  either  from  above — that  is,  from  tiie  Ivithieys — or,  much  more  com- 
monly, from  behjw  and  witiiout — tiiat  is,  tlirongh  tiie  urethra  by  un- 
ck'unly  instrumentation.  According  to  Kovsing,'  the  causative  factor 
of  cystitis  is  the  presence  of  j)yogenic  sta})hyk)cocci  and  strej)ti)Cocci. 
Schnitzicr's^  investigations  of  twenty  patients  sufltcring  from  purulent 
cystitis  resulted  iu  the  finding  of  a  bacillns  in  thirteen  of  these  cases, 
M'hich  he  named  iti'o-bacillu.s  pyogenes  scpticu.s.  All  of  the  organisms 
causing  cystitis  are  anaerobic ;  hence  they  are  not  identical  witii  the 
germs  that  induce  the  decomposition  of  voided  urine. 

Fortunately,  the  introductiijn  of  septic  germs  into  the  healthy  blad- 
der is  not  always  and  necessarily  followed  by  cystitis.  Ordinarily,  a 
moderate  amount  of  noxious  germs  accidentally  intrixhiced  in  the  blad- 
der will  be  prom])tly  removed  with  the  urine.  Infection  will  take  place 
much  more  readily  where  morbid  conditions — as,  for  instance,  stone  or  a 
tumor — are  jiresent ;  and  these  are  the  very  instances  in  which  instru- 
mentation of  the  bladder  is  demanded.  On  the  other  hand,  it  nuist  be 
clearly  stated  that,  both  according  to  the  experience  of  practice  and 
according  to  the  results  of  ex|)crinK'nt  (Schnitzlcr),  the  simple  introduc- 
tion of  pathogenetic  germs  into  a  jterfectly  normal  l)ladder  may  be  fol- 
Io\\ed  by  very  virulent  cystitis.  Therefore  we  are  morally  Ijound  to 
exercise  the  utmost  care  and  cleanliness  where  catheterism  of  the  healthy 
bladder  becomes  necessary,  as,  for  instance,  immediately  following  rectal 
operations. 

Bou'/ies  (infl  citllictcrx  mav  be  made  of  metal,  of  flexible  or  hard  rub- 
l)er,  and,  finally,  of  a  fiexii)le  material  consisting  of  a  wel)bed  textile 
groundwork  satiu'ated  with  a  giuinny  substance.  As  all  of  these  instru- 
ments need  lubrication,  and  as  the  lubricants  most  commonly  employed 
are  fats  or  oils,  the  coating  of  the  surfaces  of  the  instrument  with  fat 
will  render  disinfection  by  simple  rinsing  with  or  st)aking  in  a  germicidal 
.solution  absolutely  worthless. 

Metal  iiixtnimciifK  will  readily  lend  themselves  to  the  most  simple  and 
most  reliable  mode  of  disinfection — tliat  is,  that  by  heat.  Either  b(jil- 
ing  in  plain  water  or  soda  solution,  or  passing  the  instrument  through  a 
gas  or  alcohol  Hame  or  through  the  bed  of  glowing  coals  in  a  stove  or 
grate,  will  certainly  destroy  all  organic  life  contained  in  the  hollows  or 
upon  the  surface  of  metal  catheters.  Where  constantly  needed  they  can 
be  safely  preserved  in  glycerin  or  alcohol,  but  nuist  be  thoroughly  flushed 
and  wiped  after  each  use.     Twice  a  week  they  ought  to  be  boiled. 

More  difficult  is  the  management  of  soft-rubber  or  N&laton  catheters. 
They  can  be  thoroughly  sterilized  bi/  immersion  for  fifteen  minutes  in  a  1 
per  cent,  irnteri/  solution  of  soda  just  below  the  boiling-jjoint  without 
injury  to  their  cohesion  ami  flexibility  ;  but  this  jirocess,  re])eated  too 
often,  will  finally  make  them  hard  and  brittle.  After  a  first  disinfection 
by  heat  it  is  best  to  kec]i  them  jiermanently  sus])cnded  in  a  tall  specimen- 
jar  filled  with  either  a  5  per  cent,  solution  of  carbolic  acid  or  a  1  :  1000 
solution  of  corrosive  sublimate  frequently  renewed.  Before  use,  adherent 
traces  of  these  solutions  must  be  first  removed  by  rinsing  and  flushing 
with  boiled  water,  as  the   urethral   uuicous  membrane  is  easily  irritated 

'  Dk  Bldfcnentzundimy,  etc,  Berlin,  1S90. 

-  "Zur  Aetiologie  der  acuten  t'ystitis,"  Centralbl.  J'iir  Baclerioloyie,  IS',10,  p.  7S9. 


72(i     THE  TECHNIQUE  OF  ANTISEPTIC  AND  ASEPTIC  SURGERY. 

by  eitlier  of  these  chemicals.  After  use  all  traces  of  iii'iiic  iiiiist  be 
M'ashed  away  before  the  instrument   is  returned  to  its  reee])taeie. 

Still  more  dittieult  is  the  cleansinj;-  and  suitable  ])reservation  o^  v ebbed 
f/um  bou(/ics  and  catheters.  They  will  stand  neither  heat  nor  prolonjjjcd 
soaking  in  antiseptic  solutions,  and,  being  very  useful  and  the  better 
grades  rather  expensive,  a  practical  method  for  their  safe  management 
is  of  the  utmost  importance.  Schinnuelbusch '  has  demonstrated  that 
bri.skly-e.reeuteel  friction  of  a  webbed  gum  catheter  or  liougie  during  one 
minute  with  a  wet  compress  or  towel,  followed  by  energetic  ruhliing 
with  a  dry  sterile  cloth — as,  for  instance,  a  freshly-laundried  towel — 
iri/l  tlioroiighly  dimnfect  j7.«  .mrface,  even  if  it  was  previously  smeared 
with  and  soaked  in  fojtid  jjus. 

How  to  sterilize  the  hollow  interior  of  these  webbed  catheters  was 
unsolved  until  L.  Farkas  of  Budapest  constructed  a  small  poi'table 
steam-boiler  with  safety-valve  and  conical  nozzle,  upon  which  is  slipped 
the  base  of  the  rubber  or  gum  catheter  to   be  disinfected.     Steam  is 

Fig.  198. 


CatlH'Ur  >lri  ilizt-r  of  Farkas. 


gotten  up  in  a  few  minutes  over  a  gas  or  alcohol  flame,  and  is  made  to 
escape  through  the  hollow  of  the  catheter  without  injury  to  its  quality. 

The  lubricant  employed  in  catheterism  also  needs  attention,  as  it  may 
be  the  carrier  of  infection.  Glycerin  is  preferable  to  fats.  Both 
glycerin  and  fats  or  oils  siiould  be  boiled  before  use.  It  is  best  to 
preserve  them  in  metal  cans  or  collapsible  tubes  that  permit  the  escape 
of  a  small  quantity  only,  just  sufficient  for  one  lubrication.  Machine- 
oil  cans,  or  for  vaseline  paint-tubes,  will  ensure  against  contamination 
of  the  bulk  of  their  contents.  If  is  h((d.  practice  to  dip  the  instrument 
into  the  bottle  or  can   filled  irilli   the  lubricant. 

Finally,  before  doing  catheterism,  it  is  important  to  consider  the  con- 
dition of  the  urethra,  which,  according  to  Lustgarten  and  INIannaberg,^ 
regularly  harbors,  even  in  its  normal  state,  a  variety  of  micro-organisms, 

'  Anieitung  zur  asepi.  WimdbehaniHung,  1892,  p.  129. 

'^  "  Ueber  die  Micro-organisnien  der  nnrmalen  miinnlichen  Urethra,  etc.,"  Vierteljahr- 
scfirift  fill'  Dermatologie  unci  Syphilis,  1S87,  No.  4. 


REGIONAL  TECHNIQUE.  727 

some  of  which,  carried  into  the  bladder  by  the  catheter,  are  capable  of 
inducing  cystitis.  In  thv  presence  of  a.  virulent  urcfhrUli^  catluieri.sni  is 
uhsohdely  prohibite<T,  and  even  evacuation  by  suprapubic  puncture  de- 
serves the  preference. 

The  milder  forms  of  urethritis  do  not  absolutely  forbid  the  use  of 
urethral  instruments,  but  any  form  of  instrumentation  in  presence  of 
urethral  irritation  is  justified  only  under  urgent  indications,  and  must  be 
preceded  by  a  vrri/  tliorour/h  irrir/cdioti  of  the  anterior  a nfl  posterior  parts 
of  the  urethra.  The  principal  objt'Ct  of  this  is  the  mechanical  dislodge- 
ment  of  the  tenacious  mucus  (uretliral  threads)  coating  especially  the 
recesses  of  the  urethra. 

Whenever  possible  the  urethra,  as  well  as  the  bladder  itself,  should 
be  thoroughly  M'ashed  out  before  an  incisive  exploration  or  operation  is 
to  be  done  in  these  organs.  Or,  if  this  be  impossible  before,  it  should 
be  done  as  soon  d urine/  the  pjrof/rei<s  of  the  operation  as  access  is  gained 
to  the  urethra  and  bladder. 

Normal  salt,  or  Thiersch's,  or  boracic-acid  solution,  or  plain  boiled 
water,  is  to  be  used  rather  than  carbolic  acid  or  sublimate. 

Since  the  regular  emj)loymcnt  of  the  preliminary  toilette  of  the 
urethra  j)receding  exploration  and  urethral  operations,  the  frequency  of 
urethral  fever  has  been  remarkably  diniinislied. 

Another  important  element  of  the  j)reparation  of  the  urinary  channels 
for  explorations  and  operations,  especially  where  (ystitis  and  pyelitis  are 
an  established  complication,  is  the  internal  administration  of  certain  bal- 
.samic  substances  and  of  some  mineral  and  organic  acids.  By  their  ex- 
hibition for  some  time  before  an  operation  the  quality  of  the  urine  may 
be  materially  improved  in  several  ways.  Its  alkaline  reaction  may  be 
changed  to  acidity,  and  its  contents  of  pus  may  be  eonsi<leral:)ly  dimin- 
ished. (For  further  particulars  the  reader  is  referred  to  the  paper  on 
the  Surgery  of  the  Urinary  Organs.) 

The  female  c/cniial  tract  also  needs  special  ])reparation  for  all  forms 
of  surgical  interference  with  its  constituent  organs.  The  vagina,  even  in 
its  normal  state,  serves  as  the  habitat  of  numerous  more  or  less  noxious 
organisms,  which  thrive  luxuriantly  in  the  moist,  warm  pabulum  of  vagi- 
nal mucus  and  decayed  epithelia.  No  thorough  cleansing  can  be  effected 
by  an  antiscjjtic  douche  alone,  as  this  is  unable  to  wash  out  all  the  effete 
material  lodged  in  the  folds  and  reflections  of  the  mucous  membrane. 
To  reach  a  satisfactory  state  of  vaginal  cleanliness  soaji,  hot  water,  ami  a 
narrow  vaginal  or  jeweller's  brush  (Fig.  199)  have  to  be  plied  energetic- 

Fui.  199. 


ally  until  all  effete  material  is  loosened.     After  this  it  can  be  readily 
washed  away  by  the  jet  of  tlic  douche. 

The  endometrium  and  lining  of  the  cervical  canal  will  also  need  a 


728     THE  TECHNIQUE  OF  ANTISEPTIC  AND  ASEPTIC  SURGERY. 

special  (•k'un^ing'  liuforc  any  exploration  or  operation  involving  a  lesion 
of  continuity  of  the  orj^an  can  be  undertiikeii.  If  the  os  is  contracted,  it 
will  have  to  be  dilated  to  give  access  to  the  blunt  or  sharp  curette,  irri- 
gating ])oint,  and  iddoforni-ganze  packing.  Especially  wlien  a  purulent, 
catarrlial,  or  ulcerative  ])roccss  or  neoplasm  is  present  this  scoojiing  away 
of  septic,  broken-down  material  must  be  very  tiiorougli  to  prevent  an  in- 
fection of  the  peritoneal  cavity.  As  seen  by  the  i)rcccding  remarks,  here 
also  as  elsewhere  mechanical  processes  of  depuration  constitute  the  main 
portion  of  disinfection. 


OPERATIVE  SURGERY. 

By  8TEPHEN  SMITH,  M.  D. 


No  openition  slioukl  ho  performed,  except  in  urgent  cases,  unless  the 
patient's  liistorv  and  general  condition  have  been  scrupulously  inquired 
into  ;  even  in  cases  demanding  an  immediate  oj)eration  there  may  still  be 
opportunity  for  inquiry  as  to  previous  health  and  habits,  and  to  examine 
the  heart  and  lungs,  and  perhaps  the  secretions  of  the  kidneys.  In  de- 
layed operations  the  surgeon  would  be  culpably  negligent  who  did  not 
inquire  into  constitutional  peculiarities  and  functional  and  organic  affec- 
tions, for  the  timely  discovery  of  morbid  conditions  of  the  viscera  renders 
pi)ssil)le  the  use  iif  appropriate  remedies  before  the  oi)cration.  The  occa- 
sional fatal  results  of  anaesthetics  are  sometimes  cUie  to  organic  diseases 
of  the  kidneys,  which  by  proper  care  might  be  protected  from  the  injurious 
effects  of  these  agents. 

Diag-nosis. — It  is  not  always  possible  to  discover  the  exact  condition 
of  a  diseased  or  injured  organ  or  tissue,  anil  it  is  a  fact  of  daily  experience 
that  surgeons  of  the  greatest  skill  will  differ  in  their  diagnosis  of  the 
nature  of  a  given  disease,  but  failure  to  detect  the  more  obvious  and 
essential  changes  will  always  be  construed  as  culpable  negligence.  As  it 
is  admitted  tliat  errors  in  diagnosis  are  due  in  a  great  majority  of  cases 
to  haste  and  inattention,  tiie  surgeon  should  seek  by  tiiorough  and  patient 
investigation  of  every  case,  aided  by  the  most  approved  instruments  and 
a])pliances,  to  protect  himself  from  such  a  charge.  The  elements  of  a 
correct  tliagnosis  are  found  in  the  history  of  the  patient,  the  causes  and 
progress  of  the  disease,  and  the  physical  examination. 

1.  The  hiiitori/of  the  })atient  includes  the  following  series  of  inquiries: 
Sex,  in  its  tendencies  to  special  forms  of  disease  at  different  periods  of 
life  and  to  nervous  phenomena  ;  age,  as  it  affects  the  development  of 
bones  and  organs,  the  integrity  of  tissues,  and  the  occurrence  of  organic 
and  malignant  diseases ;  heredity,  in  the  perpetuation  of  diseases  and 
peculiarities  of  ancestors  ;  previous  diseases,  which  leave  their  sequelae, 
as  syphilis,  scrofula ;  occupation,  which  develops  special  maladies,  as 
necrosis  of  jaw  from  ph()s|)horus  ;  ]ial)its,  with  which  certain  affections 
are  likely  to  be  associifted,  as  venereal  diseases  with  prostitution,  nervous 
derangements  with  niastu'-bation  ;  social  condition,  as  it  is  related  to 
secret  or  conjugal  vices  of  the  sexes. 

2.  The  jM-oc/ress  of  the  disease  relates  to — date  of  the  attack  or  injury, 
on  which  dejiends  the  progress  of  the  malady ;  alleged  changes,  which 
may  be  tlie  clue  to  the  true  cause  ;  symptoms  which,  taken  in  their  ovthr 
of  development,  giv(^  much  of  the  clinical  history  and  aiVord  reliable  data 
for  a  differential  diagnosis  ;  the  present  attitude,  form,  and  condition  of 
the  part  compared  w  ith  the  past ;  tlu'  operations  which  may  have  been 

729 


730  OPERATIVE  SURGERY. 

performed  and  their  residts  ;  the  eourse  of  treatment  and  its  most  im- 
portant cifects,  whicii  may  he  tiie  very  touchstone  reveahng  tlie  nature 
of  the  comphiint. 

.'>.  The  plujmcal  cxoiiiiiinfloii  must  he  made  with  all  necessary  aids 
and  ap])liances,  visual,  mannai,  and  instrumental.  1.  Color  determines 
the  circulation  in  a  part;  form  indicates  the  existence  or  non-existence 
of  enlargements  of  regions  when  deciding  as  to  tumors,  dislocations, 
fractures ;  translucency  reveals  the  presence  of  serum,  as  in  hydrocele. 
2.  Consistence  must  he  noted  in  inflammatory  swellings  and  tumors;  fluc- 
tuation in  collections  of  fluids;  crei)itus  in  fractures;  crepitation  in  col- 
lections of  air  or  gas  beneath  the  skin.  3.  The  exploring  needle  detects 
the  consistence  and  contents  of  swellings  and  tumors ;  the  hypodermic 
syringe  withdraws  the  fluids  of  abscesses  and  cavities;  the  trocar  removes 
pieces  of  muscle  for  examination  ;  the  microscope  determines  histological 
peculiarities  ;  the  oj)hthalmoscope  reveals  the  deep  structures  of  the  eye, 
the  laryngoscope  of  the  laryngeal  jiassages,  the  speculum  of  the  ear,  the 
vagina,  and  rectum,  the  urethroscope  of  the  urethra,  and  the  endoscope 
of  the  urinary  bladder.  With,  antiscjitic  precautions  exploratory  opera- 
tions may  now  be  safely  made  for  the  purpose  of  accurate  diagnosis. 

Prognosis. — The  prognosis  is  an  estimate  of  the  results  which  will 
follow  any  operation.  It  must  dejiend  primarily  upon  the  knowledge 
obtained  in  the  diagnosis,  and  secondarily  upon  that  larger  inquiry  which 
seeks  to  discover  tendencies  and  conditions  alfecting  the  ultimate  issue  of 
diseases  and  operative  procedures  undertaken  for  their  cure.  Due  weight 
must  be  given  to  the  steady  imj)rovements  in  the  details  of  the  treatment 
of  wounds  and  the  constant  enlargement  of  the  field  of  operations.  The 
mortality  of  ordinary  operations  has  been  surprisingly  reduced  by  the 
em|)loyment  of  means  of  jircventing  sujipuration,  while  the  range  of  ope- 
rations is  daily  and  rapidly  increasing.  The  following  facts  are  always 
Avorthy  of  consideration,  whatever  may  be  the  ojieration  :  1.  The  native 
bears  operations  better  than  the  immigrant.  2.  The  sex  which  has  the 
greatest  endurance  is  the  female.  3.  The  age  is  not  in  itself  a  barrier  to 
any  necessary  operation  ;'  however,  with  it  we  connect  the  most  regular 
average  diiference  in  capacity  to  bear  operations ;  the  most  favorable 
period  is  between  five  and  fifteen  ;  tlie  next,  between  fifteen  and  thirty  ; 
after  thirty  the  risk  to  life  is  more  tlian  twice  as  great  as  it  was  at  the 
same  period  after  birth.  Young  and  healthy  children  are  in  danger 
through  shock,  aggravated  by  pain,  Init  bear  very  well  the  loss  of  blood 
and  are  little  liable  to  pysemia  after  wounds.  Old  persons  are  likely  to 
have  organic  diseases  and  degeneracies,  and  feeble  circulation,  inducing 
congestions,  due  to  the  sinking  of  the  blood  in  the  lungs,  liver,  intestines, 
and  other  dependent  parts;  are  liable  to  die  of  shock  or  mere  exhaus- 
tion, and  do  not  bear  losses  of  blood,  lowering  of  temperature,  or  want  of 
food ;  they  convalesce  slowly,  or  after  partial  recovery  fade,  waste,  and 
die ;  but  the  thin,  dry,  tough,  clear-voiced,  and  bright-eyed,  with  good 
stomach  and  strong  will,  nniscular  and  active,  bear  very  well  all  but 
the  largest  operations. 

Constitutional  diseases  greatly  modify  the  prognosis.  In  general  they 
influence  operations  as  follows  :  Scrofula  gives  a  considerable  mortality  ;' 
generally  its  ill   eifects  are   seen  chiefly  in  the    imperfect    healing  of 

'  Paget. 


'       OPERATIVE  SURGERY.  731 

wounds,  the  swollen  cellular  tissues,  the  thin  anil  lowly-organized  cica- 
trix, or  indolent  ulcers  :uid  siiuises  ;  in  the  large  majority  of  chronic  cases 
the  removal  of  a  scrofulous  part  is  followed  l)y  impixived  health,  but  the 
])atient  remains  scrofulous,  and,  if  old,  may  uot  bear  confinement  well. 
Syphilis  is  liable  to  delay  reparative  action,  and  the  operation  in  those 
who  have  tertiary  sores  may  be  followed  by  renewed  tertiary  symptoms ; 
rheumatism  and  gout  ]iredispose  to  structural  clianges  of  arteries  and  kid- 
neys and  to  organic  disease  of  the  heart ;  cancer  contraindicates  ope- 
rations only  in  its  later  stages,  when  th(>  general  health  is  failing ;  an;emia 
is  not  a  bad  condition  in  which  to  operate ;  wounds  heal  slowly  and 
soundly,  but  if  erysipelas  or  like  casualties  supervene  patients  are  less 
likely  to  recover. 

Habits  and  temperament'  should  also  l)e  duly  considered;  intem- 
perance increases  the  dangers  of  operations  in  ])ro])ortion  as  it  is  habitual ; 
slight  intemperance  is  much  worse  than  occasional  great  excesses;  avoid 
oj)erating  on  confirmed  drunkards,  unless  compelled  by  the  necessity 
of  the  case ;  operations  are  hazardous  on  all  persons  who  require  stimu- 
lants before  tliey  eat  or  work ;  over-eating  is  closely  allied  to  intem- 
perance in  increasing  the  dangers  of  operations,  especially  if  the  over- 
eating is  of  meat  and  other  nitrogenous  foods  ;  the  over-fat  are  a  bad  class 
when  their  fatness  is  not  hereditary,  but  due  to  over-eating,  soaking,  indo- 
lence, and  defective  excretions,  their  pendulous  bellies  indicating  omental 
fat  and  deficient  portal  circulation  ;  persons  in  whom  the  vital  processes 
are  M'cak,  lint  without  morbid  action,  repair  wounds  feebly,  and  are  espe- 
cially liable  to  diseases  of  the  blood  and  tissues,  and  operations  u])on  such 
persons  should  be  deferred,  if  practical)le,  to  some  ])eriod  of  l)t'tter  health, 
for  fear  of  Im'al  f:iilui-e,  rather  than  of  incurring  any  unusual  risk  of  life  : 
allied  to  this  class  are  the  cold-blooded,  with  cold,  damp  hands  and  feet, 
dusky  appearance  of  vascular  parts,  feeble  circulation,  small  pidse,  slow 
digestion,  constipation  ;  nervous  persons,  who  are  exceedingly  mobile  and 
excitable,  whether  in  their  sensitive  or  motor  organs,  their  whole  cereI)ro- 
spinal  system  being  altogether  too  alert  and  vivacious,  pass  through  the 
conse(|uences  of  ojterations  with  as  great  imjtnnity  as  any  other  class ; 
malarial  affections  do  not  contraindieate  operations,  but  in  the  course  of 
con\'alescence  ague  fits,  resembling  those  which  precede  pyaemia,  may  occur. 

Deranged  or  diseased  conditions'  of  many  organs  variously  affect  the 
results  of  operations.  Of  the  digestive  organs,  gastric  dyspepsia  is 
followed  only  by  flatulence,  unless  vomiting  is  a  symptom,  when  anaes- 
thetics are  liable  to  excite  cmesis,  with  dangerous  prostration  ;  great 
caution  is  required  with  those  whose  biliary  secretions  are  habitually 
unliealtiiy,  or  who  have  been  often  jaundiced,  or  who  have  a  sallow, 
dusky  complexion,  dry  skin,  dilated  small  blood-vessels  of  the  face,  sal- 
low and  l)loodshot  coirjunctivtc — symptoms  which  indicate  deranged  func- 
tions and  aixlominal  plcth'ira  ;  eidargemcnt  of  the  liver,  wiictiier  amyloid 
or  fatty,  is  often  coincident  with  chronic  diseases  of  the  bones  in  children, 
and  tends  to  cause  dcatli  either  b}'  exhaustion  or  secondary  hemorrhage. 
Of  the  organs  of  circulation,  affections  of  the  heart  are  not  serious  liind- 
rances  to  recovery  from  operations  ;  shock  and  loss  of  blood  are  attended 
with  more  than  ordinary  risk  in  jiersons  whose  hearts  are  feeble  or  embar- 
rassed i)y  valvular  obstruction,  but  a  rapid  or  irregular  pulse,  witliout 

'  Paget. 


732  OPERATIVE  SURGERY. 

(irfiaiiu!  disease  of  tlie  heart,  and  witli  respiration  not  exceedinjj  20  or  25, 
does  not  contraindicate  an  operation  ;  degeneraeies  of  the  arteries  are 
only  serious  wiien  general  in  the  extremities,  espeeially  the  lower,  render- 
ing ]>rinuirv  licniorrhage  ditiicult  of  eontrol,  and  seeondar\-  hemorrhage 
more  fVe<|U('nt  and  dangerous  after  amputation,  and  so  interfering  witii 
miti'ition  that  desti'uetive  suppuration  is  liahh'  to  oeeur,  with  slow  and 
imperfeet  iiealing  of  the  wound  ;  diseased  veins  complieate  operations 
only  when  varicose,  and  cut  through,  as  in  amputations,  thus  exciting 
inflammation.  Of  the  diseases  of  the  resjiiratory  organs,  chronic  hron- 
cliitis  and  empliysema,  especially  in  old  jteopie,  render  operations  ex- 
tremely hazardous,  owing  to  imperfect  respiration,  cough,  and  loss  of 
slec]) ;  ])htliisis,  wlieii  progressive,  adds  greatly  to  tiie  dangers  of  ope- 
rations from  the  consequent  fever,  loss  of  food,  and  pain,  hut,  when  chronic, 
operations  are  advisable  which  relieve  the  system  of  jiainful  and  wasting 
local  diseases  ;  persons  suffering  from  long-standing  strumous  affections, 
with  the  appearance  only  of  tui)ereular  disease,  may  be  greatly  benefited 
by  the  removal  of  the  diseased  ])art ;  menstruation  and  pregnancy  are 
conditions  rendering  operations  uudesiral)le. 

Various  other  affections  '  often  motlify  the  prognosis  as  foUoM's  :  Severe 
operations  during  the  stage  of  shock  after  injuries  and  during  the  period 
of  acute  inflammation,  with  high  temjierature,  are  dangerous ;  sjireading 
erysi])elas,  cellulitis,  and  gangrene  add  so  nnich  to  the  dangers  of  severe 
operations  tliat  the  chances  of  life  are  best  when  only  the  ordinary  treat- 
ment is  followed  :  avoid  operations  in  acute  ])y;enua  when  there  are 
rigors  once  or  more  in  a  few  days,  and  profuse  sweatings,  with  very 
rapid  pulse  and  breathing,  and  with  delirium  and  rai)id  wasting,  or  with 
dry  tongue  and  yellowness  of  skin,  or  any  considerable  number  of  these 
symptoms;  but  an  operation  is  justifialile  in  chronic  jtysemia  when  there 
are  wasting  and  sweating,  \vitli  tiu'  formation  of  al^scesses  here  and  there, 
and  tlie  injured  ])art  is  manifestly  useless  and  a  source  of  irritation  or  of 
exiiaustion  ;  crouji  does  not  contraindicate  tracheotomy,  nor  peritonitis 
herniotomy,  \v'hich  are  operations  of  necessity,  and  are  not  materially 
affected  by  the  general  acuteness  of  the  existing  affections.  Of  the  dis- 
eases of  the  kidn(y,  those  associated  with  the  constant  presence  of  albu- 
min in  the  urine  predispose  ojxTatcd  patients  to  erysij)c]as  and  jiyelitis. 

Decision  as  to  Operation. — The  (pie.stion  of  an  operation  enters  as  a 
new  and  most  important  element  in  the  ease,  and  always  demands  the  mo.st 
serious  consideration,  for  cutting  operations  must  be  regarded  as  injuries, 
inflicted  at  the  will  of  the  surgeon,  \\hich  may  destroy  a  person  enjoying 
comparatively  good  health,  or  fatallv  aggravate  other  but  not  serious  affec- 
tions. The  question  of  operation  may  l>e  involved  in  doubt  and  uncer- 
tainty, re((uiring  for  its  projx'r  solution  a  nice  a]»])reciation  of  pathological 
conditions,  operative  procedures,  and  reparati\-e  processes.  Surgeons 
may  honestly  differ  in  their  views  as  to  whether  an  operation  would 
]iroduce  a  cure,  or  be  of  some  benefit  although  not  a  radical  cure,  or 
whctlier  the  benefit  would  justify  the  operation,  or,  finally,  whether  the 
operation  could  l)c  ])erformed  at  all  without  destruction  of  life.  An 
operation  is  not  justifiable  when  the  patient  can  be  cured  by  any  medical 
or  other  means.  If  the  disease  can  be  cured  by  a  bloodless  operation, 
as  well  as  by  one  with  cutting,  choose  the   bloodless  method,  for  the 

'  Paget. 


THE  GENERAL  PREPARATION  FOR   THE  OPERATION.        733 

danti'ci'  is  comparatively  sliglit  when  the  operation  does  not  involve  the 
injury  of  tissues.  The  object  of  the  surgeon  is  twofold — viz.  to  save 
life  and  to  promote  comfort.  He  must  never  argue  that  life  is  not  worth 
saving  or  jjrolonging.  Any  operation  is,  therefore,  of  undoubted  pro- 
priety which  is  immediately  necessary  to  save  life,  as  tracheotomy  in 
laryngeal  obstructions,  excision  of  poisoned  wounds ;  or  when  it  is  less 
severe  tlian  other  measures,  as  excision  of  small  growths,  instead  of  em- 
ploying caustics;  or  wiien  it  is  the  only  measure  possible,  as  amputation 
of  cruslied  limbs;  or  the  last  resort,  all  other  suitable  remedies  having 
failed,  as  lieruiotomy  in  strangulated  hernia.  Or,  if  an  operation  prom- 
ises a  complete  cure  or  long  immunity  from  an  otherwise  certainly  fatal 
malady,  it  is  right  to  operate,  though  the  procedure  be  severe  and  dan- 
gerous, as  in  the  removal  of  cancerous  growtlis.  An  operation  is  also 
justifiable  wlien  there  is  a  reasonable  jtrobability  that  it  will  promote 
comfort,  thougli  it  does  not  eradicate  the  disease,  as  in  excising  a  can- 
cerous growth.  In  whatever  form  the  question  of  an  operation  is  j)re- 
sented,  all  of  the  evidence  for  and  against  it  shoukl  be  personally 
considered  by  the  surgeon  with  judicial  impartiality.  He  should  never 
be  over-persuaded  by  patient  or  friends,  nor  undtdy  influenced  by 
counsel,  to  oi)erate  against  convictions  deliberately  formed.  Neither  the 
consent,  nor  even  re((uest,  of  the  patient  can  justify  such  an  operation. 

The  consent  of  the  patient,  or  of  those  resj)onsil)le  for  him,  to  the 
operation  sliould,  if  jjossible,  always  be  obtained.  If  he  is  not  capable, 
as  when  intoxicated  or  comatose,  or  if  he  is  a  child  and  parents  or  guar- 
dian are  inaccessible,  operate  only  from  clear  necessity.  In  order  that 
he  or  tliey  may  form  a  correct  judgment,  conununicate  the  decision  and 
the  reasons  tiiat  liave  led  to  the  conclusion  ;  make  every  necessary  expla- 
nation as  to  the  nature  of  the  injury  or  malady,  its  jirolxible  course  and 
termination,  and  the  advantages,  disadvantages,  and  liabilities  of  the 
proj)osed  operation  :  thus  you  will  discharge  every  obligation,  and  remit 
to  the  patient  or  friends  or  guardian  the  responsibilities  of  a  final  judg- 
ment as  to  the  course  of  procedure.  As  fir  as  practicable,  the  delib- 
erations of  the  ])atient  and  his  advisers  should  be  influenced  by  no  other 
considerations  than  tliose  presented  by  the  surgeon.  Should  the  decision 
be  favorable  to  an  O|)eration,  the  patient  again  returns  to  the  surgeon's 
care  and  a  new  series  of  obligations  is  incurred.  The  pre])ai"ation  for 
the  operation,  its  manual  performance,  and  the  after-treatment  present 
questions  which  will  tax  his  knowledge,  skill,  and  care. 

The  General  Preparation  for  the   Operation. 

No  ingenuity  of  conception  or  brilliancy  of  execution  of  the  operator 
can  excuse  the  neglect  .to  secure,  by  previous  preparation,  every  possible 
advantage  which  can  in  any  way,  however  trivial,  minister  to  success  ; 
even  a  successful  issue  cannot  justify  tlie  siu'geon  in  sul)j('eting  his  patient 
to  an  avoidal)le  risk.  He  shoukl  strive  to  make  the  ]irognosis  less  seri- 
ous and  to  assure  the  success  of  the  operation.  Tiiis  residt  lie  will  more 
certainly  attain  by  properly  prejiaring  tlie  ])atient,  choosing  the  most 
favorable  moment  for  the  operation,  adojiting  the  best  method  of  })er- 
forming  it,  and  a]iplying  the  most  efficient  dressing. 

The  Preparation  of  the  Patient. — The  first  care  nuist  be  given  to 


734  OPERATIVE  SURGERY. 

the  patient.  It  is  iniportaiit  that  every  organ  and  the  entire  system  he 
so  prepared  for  tiie  injury  ahout  to  he  intiieted  tiiat  the  issue  will  be 
favoi'able,  for  the  timely  discovery  of  morbid  conditions  of  the  viscera 
and  the  use  of  appropriate  remedies  Ix'fore  the  operation  might,  in  a 
large  proportion  of  cases,  prevent  disastrous  results.  The  efl'eets  of 
hal)its  of  excessive  boflily  indulgence  in  food  and  stimulants  may  be 
amended  in  a  comparatively  short  time  ;  jtrevious  rest,  important  to  the 
recovery  of  the  part  about  to  be  operated  upon,  may  be  secured  ;  slight 
derangements,  which  are  readily  amenable  to  treatment,  such  as  indiges- 
tion, constipation,  diarrluea,  may  at  once  be  corrected;  grave  affections 
of  the  kidneys,  liver,  heart,  lungs,  and  nervous  centres  may  be  so  im- 
proved or  the  system  so  protected  that  the  o])eration  will  not  be  serious'. 
Even  ansemic  persons  with  feeble  circulation,  when  suitably  pre- 
pared by  tonics,  as  iron,  improve  their  condition  and  bear  operations 
well,  being  singidarly  little  liable  to  erysipelas,  pyaemia,  and  other  dis- 
orders of  the  blood.  The  patient  should  be  placed  under  the  most 
favoralile  hygienic  conditions;  jnire  air,  suitable  exercise,  Mholesome 
food,  and  undisturbed  slee|)  are  im])ortant  features  in  the  final  ])rej)ara- 
tion  ;  the  morale  nuist,  as  far  as  possible,  be  sustained  by  such  assurances 
as  will  secure  mental  quietude  and  hopefulness  as  to  the  result  of  the 
operation  :  do  not  exaggerate  its  nature,  but  speak  encouragingly  of  it 
and  of  its  prospeeti\-e  success.  Finally,  as  a  severe  shock  to  the  nervous 
system,  produced  by  an  exhaustive  surgical  operation  and  ]irolonged  an- 
sesthesia,  may  for  a  time  so  paralyze  the  stomach  that  digestion  ceases  or 
is  greatly  impaired,  and  the  food  that  it  contains  at  the  moment  may 
undergo  such  putrefactive  changes  as  will  render  it  an  irritant,  the  food 
taken  within  six  hours  of  the  operation  should  be  quickly  assimilable 
and  in  limited  quantities  :  milk  is,  in  general,  the  best  food  for  this  pur- 
pose, especially  with  children,  to  which  may  be  added  a  small  amount 
of  whiskey  ;  a  warm,  well-seasoned,  and  well-cooked  cup  of  broth  or  a 
fragrant  cup  of  hot  coffee  and  milk  may  be  preferred  by  the  adult. 

The  Time  for  the  Operation. — The  time  appointed  must  be  so  fixed 
as  to  avoid  the  error  of  omission,  delay — or  of  commission,  haste— by  a 
careful  consideration  of  tlie  nature  of  the  disease,  the  condition  of  the 
patient,  and  the  surrounding  circumstances.  It  must  be  immediate 
when  life  is  threatened  and  the  operation  offers  the  only  chance  of  re- 
covery, and  should  be  delayed  when  any  of  the  conditions  enumerated 
would  render  the  operation  dangerous  to  life  or  abortive  in  its  results. 
But  not  unfrequently  the  disease,  the  patient,  and  the  circumstances 
combine  to  enable  the  surgeon  to  appoint  the  month,  the  day,  and  the 
hour.  The  emi)loyment  of  anrestheties  has  so  diminished  the  fear  of 
operations  tliat  the  surgeon  may  exercise  his  discretion  as  to  the  propri- 
ety of  informing  the  patient  of  the  day  and  hour  selected. 

The  Place  for  the  Operation. — In  the  selection  of  the  place  refer- 
ence must  be  had  to  the  comfort  and  safety  of  the  patient.  The  office 
of  the  surgeon  is  frequently  the  most  convenient  place,  but  a  risk  to 
the  ]iatient  may  thereby  be  incurred,  which  it  is  better  to  a\-oid — namely, 
the  liability  of  rendering  a  simple  operation  dangerous  by  the  subse- 
quent imprudent  conduct  of  the  ]Kitient,  as  exposure  to  the  elements, 
excitement,  f\itigue,  or  excesses  of  appetite. 

The  room  in  the  private  dwelling  should  be  chosen  for  its  accessibility, 


THE  GENERAL  PREPARATION  FOR   THE  OPERATION.        735 

its  size,  and  its  exposure  to  light  at  tlie  liour  of  the  ()i)eration  ;  tlie  best 
liofht  on  a  clear  day  for  delicate  operations  is  reflected  from  tlie  nortliern 
sky.  The  air  of  the  room  in  which  an  operatiou-wonnd  is  inllictcd 
should  be  as  free  as  it  can  be  made  from  all  forms  of  putrefactive  organ- 
isms ;  it  should  not  immediately  communicate  with  water-closets  and 
other  sources  of  defilement,  nor  be  occupied  as  a  living-  or  audience- 
I'oom.  The  best  results,  after  large  oiierations,  have  been  obtained  when 
the  operating-room  has  been  first  purified  the  preceding  day,  and  l)oth 
operator  and  assistants  have  bathed  and  had  their  clothes  and  all  the 
materials  used  about  the  wound  thoroughly  disinfected. 

The  Selection  of  Instruments. — In  selecting  instruments  care  must 
be  taken  that  they  are  of  approved  utility  and  in  good  condition.  The 
surgeon  cannot  employ  rude  articles,  as  a  butcher's  knife  or  a  carpen- 
ter's saw,  in  amputation,  unless  he  is  placed  under  circumstances  which 
prevent  his  oi)taining  suitable  instruments.  And  he  is  required  to 
employ  the  more  recently  devised  instruments  which  liave  been  recom- 
mended by  the  best  authorities  as  preferable  to  those  formerly  in  use, 
provided  they  are  reasonably  accessible  to  him.  They  should  be  so 
constructed  as  to  be  readily  made  aseptic  and  maintained  in  that  condi- 
tion. For  this  jjurpose  the  handle  should  be,  as  far  as  practicaljle, 
smooth,  and  made  from  non-absorbent  material,  and  the  setting  of  the 
blade  or  shatt  should  iiave  no  recesses  for  filth.  They  must  be  kept  in 
good  order,  as  dull  knives,  broken  forceps,  or  imperfect  saws  seriously 
complicate  operations.  They  must,  finally,  be  kept  in  a  state  of  scrupu- 
lous cleanliness,  as  blood  and  pus  may  convey  contagion  to  the  person 
next  operated,  and  dust  and  filth  may  fiitally  poison  a  wound.  The 
miniu-  apparatus,  also,  nuist  be  carefully  selected,  for  an  operation  may 
be  spoiled  by  sometliiiig  tliat  was  tliought  too  trivial  for  care. 

The  testti  of  the  quality  of  instruments  are  as  follows  :  Draw  a  cutting 
instrument  from  heel  to  point  slowly  across  the  border  of  the  nail,  and 
it  will  catch  or  stop  at  every  "nick ;"  draw  it  across  the  ffat  of  the  nail, 
and  if  at  any  point  the  edge  is  seen  to  be  wiry  or  smooth,  it  is  soft,  and 
must  be  reapplied  to  the  hone;  ])ut  if  it  becomes  serrated  like  a  fine 
saw,  the  edge  is  brittle  and  camiot  be  remedied  by  the  hone.  For 
pointed  instriunents  stretch  upon  a  test-drum  (a  contrivance  for  the 
piu-pose  for  sale  by  instrument-makers)  a  very  thin  piece  of  kid  or  gold- 
beater's skin  and  push  the  point  through.  If  it  enter  smoothly  and 
easily,  the  point  is  good ;  but  if  a  slightly  crackling  noise  is  heard,  it 
is  defective.  If  a  lancet  is  tested,  see-saw  the  edge  in  the  opening,  and 
if  it  glides  over  without  cutting  or  cuts  rougiily  the  edge  is  imperfect. 

The  preservation  of  instruments  in  good  condition  requires  carefid 
attention  to  tlie  following  details  :  Select  a  place  always  free  from  moist- 
ure and  dirt  fi>r  tlieir  safe-keeping.  Polished  instruments  shoidd  be 
suspended  or  placed  in  metallic  cases.  After  being  used  every  in- 
strument siiould  be  thoroughly  cl(>aned  with  warm  water,  and  perfectly 
dried  witli  cliamois  or  the  fire  before  it  is  returned  to  the  ease.  Silver 
instruments  tarnish  when  tiiev  arc  exjiosed  to  the  air  or  are  brought  in 
contact  with  hard  or  soft  rubber,  caustics,  or  acids.  To  preserve  the 
etlge  and  polish  of  instruments,  the  surgeon  requires  two  or  three  small 
hemes,  some  fine  emery-])a|)er,  two  or  three  screw-drivers,  small  files, 
rouge,  crocus,  or  other  polishing  powder,  chamois,  antl  gold-beater's  or 


7.36  OrERATTVE  SURGERY. 

kid  skin.  C^ittinii'  iiistruiiiciits  sliould  have  their  h]aflos  kcjit  in  jH'rfcct 
onk'r  Ijy  tho  judicioiis  use  of  tlie  hone.  Oecasionally  the  blade  miLst  be 
ground  by  a  competent  workman.  Blunt  instruments,  Avhich  are 
designed  to  enter  natural  or  other  passages,  should  hv  frequently 
polished  with  fine  emery-paper,  and  then  with  rouge  and  chamois-skin, 
in  order  to  remove  every  jtartiele  of  rust  and  to  maintain  smooth, 
unblemished  surfaces.  Saws  are  sjiarpened  with  three-corncreil  files 
applied  in  the  direction  of  the  original  cut  of  the  teeth. 

The  case  of  instruments  which  the  surgeon  must  jjrovide  depends 
upon  the  variet}'  of  operations  which  he  undertakes :  if  limited  to 
ti-ifiing  operations,  he  retpiires  oidy  the  pocket-case ;  if  he  pei'form 
minor  operations,  he  requires  the  minor  operating-case;  if  he  assumes 
every  grade  of  operation,  be  must  add  the  general  operating-case.  In 
.selecting  any  case  the  surgeon  should  exercise  his  own  judgment  as  to 
the  number  and  kind  of  instruments,  rather  than  accept  the  list  of  the 
maker  or  of  any  other  surgeon.  The  best  assorted  ease  contains  many 
instruments  which  the  general  practitioner  never  has  occasion  to  use. 
The  case  which  immediately  contains  the  instruments  should  l)e  made  of 
metal,  and  should  be  adjustable,  so  that  the  whole  or  the  different  parts 
may  be  jilaced  in  boiling  water.  Aluminum  is  adapted  for  a  small  case, 
and  rolled  copper  for  a  lai'ge  case. 

Convalescence. — The  hygienic  conditions  which  surround  a  patient 
the  subject  of  an  operation  materially  affect  the  results.  Foul  air,  filthy 
dressings,  and  indigestible  food  will  thwart  the  best  ])lanned  and  exe- 
cuted o])eration.  It  is  therefore  the  duty  of  the  surgeon  to  secure  to  the 
patient  all  the  advantages  which  healthful  conditions  afford.  These  are 
largely  found  in  the  room  and  its  various  ajipointments. 

The  room  in  the  private  dwelling  best  adapted  for  convalescence  is  on 
the  secf>nd  floor  from  the  grotnid  ;  the  exposure  should  be  to  the  south, 
with  ample  window  space,  and  with  opposite  or  partially  opposing  win- 
dows for  thorough  ventilation.  The  size  of  the  room  is  of  slight  import- 
ance, except  as  to  convenience,  compared  with  the  provisions  fV)r  the  out- 
flow of  foul  air  and  the  infl(jw  of  fresh  air.  Large  cubic  sjiace  does  not 
secure  purity  of  the  air,  and  hence  is  of  minor  importance  if  the  neces- 
sary amount  of  fresh  air  is  sup])lie<l  and  properly  distril)uted  without 
unpleasant  currents.  It  would,  however,  always  be  wise  to  ])rovide  at 
least  two  hundred  feet  superficial  area  and  three  thousand  cubic  feet  of  air 
to  the  patient  and  his  attendant,  each,  during  the  first  few  weeks,  to  guard 
against  defects  in  ventilation.  As  in  private  residences  there  are  no  other 
motors  for  changing  the  air  than  differences  of  temperature  and  move- 
ment of  the  air  which  can  be  excited  by  heat  or  wind-fans,  these  agents 
must  be  employed  to  give  motion  to  the  air.  The  conunon  ojien  fire- 
place, well  heated,  furnishes  the  best  heat-supply  for  movements  of  the 
air,  while  the  inlet  and  outlet  of  air  is  maintained  by  raising  and  drop- 
ping the  sashes  of  the  windows.  The  walls  should  be  freshly  lime- 
washed,  floors  cleaned  with  carbolic  solution  ;  no  sink  for  slops,  nor 
wash-bowls  drained  into  common  house-drains,  nor  water-closet,  should 
be  in  or  communicate  with  the  room  ;  the  furniture  should  be  as  free  as 
possible  from  absorbent  materials  ;  bed-  and  window-hangings,  carpets, 
and  ujjholstery  are  objectionable,  and  if  old  are  dangerous.  Floors,  fur- 
niture, and  woodwork  should  be  cleansed,  without  water,  by  rubbing 


THE  PREVENTION  OF  HEMORRHAGE. 


737 


with  au  ab.s()rl)ont  material.  Do  not  place  the  bed  near  the  wall,  in  a 
corner,  nor  in  air-di-aughts. 

The  ward  of  the  hot^pital  to  which  tiic  patient  is  to  be  conveyed  should 
be  free  from  suppurating  wounds,  erysipelas,  and  low  forms  of  fever ; 
the  lied  should  be  exposed  to  the  sunliglit,  with  any  necessary  screen  for 
tile  face  ;  it  should  liave  at  least  one  iuuidred  feet  of  su]ierficial  area  and 
four  tliousand  cubic  tcct  of  air  ;  the  jiosition  of  the  bed  siiciuld  be  tiu'ce 
or  four  feet  from  the  wall,  witli  complete  ventilation  around  it;  if  tiie 
tick  is  filled  with  straw,  it  must  be  fresh  ;  if  a  hair  mattress  is  used,  it, 
with  the  bed-linen,  should  be  clean  and  previously  well  aired  and  sunned. 

The  nurse  should  be  skilled  in  the  care  of  persons  suffering  from 
operations,  for  freipicntly  success  depends  upon  the  skill  in  the  manage- 
ment of  the  details  of  nursing  after  special  operations.  Cleanliness  of 
the  wound,  the  patient,  the  clotiiing,  tlie  room,  is  of  the  first  importance  ; 
the  diet  and  the  remedies  are  to  be  airefidly  attended  to ;  and  the  prog- 
ress of  the  case,  as  indicated  by  the  wound,  the  pulse,  and  the  tempera- 
ture, is  to  be  noted  at  sufficiently  frequent  intervals  to  make  the  record 
of  the  case  complete  in  the  absence  of  the  surgeon. 

The  Prevention  of  Hemorrhage. 

It  is  important  to  make  suitable  preparation  for  the  prevention  of 
hemorrhage,  for  excessive  bleeding,  due  to  defective  measures  for  its 
arrest,  shows  cul]>able  negligence.  The  preparation  must  be  adapted  both 
to  control  the  cinulation  in  the  limb  or  part  during  the  operation,  and 
to  permanently  close  the  divided  vessels  after  the  o])eration. 

Elastic  Compression. — The  most  perfect  method  of  preventing  loss 
of  blood  during  the  operation  is  by  elastic  compression,  so  applied  as  to 
remove  the  blood  from  the  part  and  prevent  it  from  re-entering  the 
vessels. 

The  elastic  haiifhtf/i'  (Fig.  200)  is  tlie  most  serviceable  and  convenient 
appliance  yet  devised  to  meet  all  of  these  important  indications.  While  the 


Fio.  200. 


Fig.  201. 


(^ 


Elastitt  banUa.ije. 


Elastic  bandage  applied. 


patient  is  Iteing  brought  luider  the  ana'sthetic  apply  the  bandage,  with 
uniform  tightness,  from  tiie  extremities  of  the  toes  or  fingers,  according 
to  the  limb  about  to  be  operated  upon,  to  a  point  above  the  place  of  o])e- 
ration  ;  where  the  bandage  ends  ap]ily  india-rubber  tubing,  well  drawn 
out,  four  or  five  times  roiiii<l  the  thigh,  and  connect  one  end  with  tjic 
other  by  means  of  a  hook  and  brass  chain  ;  now  remove  the  bandage 
first  applied,  commencing  with  tiie  last  turn  and  descending  to  the  toes 
Vol.  I. — 1" 


738 


OPERA TI 1 7i'  SUE UER  Y 


Of  fiiiircrs,  leaving;;  tlic  tiil)ing  in    position 


The  l)!ui(lag(>  may  be  fixed 
with  a  .strong-  tape  j)asscd  under  the  two  or  three  hist  turns  and  tied 
firmly  ;  then  begin  with  the  first  turn  at  the  extremity  and  remove  the 
banchige  to  the  |)oint  where  it  is  fastened.  Tlie  india-rubber  tubing  so 
tlioronghly  compresses  all  the  soft  parts,  including  the  arteries,  that  not 
a  drop  of  blood  can  enter  the  parts  Ix'hnv.  Even  in  the  most  muscular 
and  obese  individuals  we  are  able  thoroughly  to  control  the  su])j)ly  of 
l)lood  l)v  this  simple  jirocess  ;  the  limb  below  the  tubing  resembles  com- 
pletely that  of  a  corpse,  and  we  may  operate  as  on  the  dead  sulyect. 
This  method  may  be  adopted  in  almost  all  operations  on  the  extremities 
with  more  or  less  complete  success.  In  extirjiatiou  of  tumors,  tying  of 
arteries,  and  in  resections  of  smaller  bones  and  joints  the  comjiressing 
tul)ing  need  not  be  relaxed  until  the  dressing  of  the  wound  is  completely 
finished.  When  operating  upon  ])arts  infiltrated  with  purulent  matters 
do  not  apply  the  elastic  bandage,  as  there  is  danger  of  forcing  the  puru- 
lent matters  upward  through  the  meshes  of  the  cellular  tissue,  but  raise 
the  limb  and  empty  the  vessels  as  completely  as  possible  before  applying 
the  tubing. 

Arterial  Compression. — The  control  of  the  circulation  may  be 
effected  by  compression  of  the  artery  which  supplies  the  ])art.  As  this 
method,  however  carefully  applied,  }>ermits  of  the  loss  of  the  blood  con- 
tained in  the  limb,  the  amount  should  be  diminished,  as  far  as  possible, 
by  first  elevating  the  limb  and  rubbing  it  towai'd  the  heart. 

The  fingers  afford  ready  and  aN-ailable  means  of  arterial  compression 
when  the  artery  is  accessible  and  lies  upon  a  bone  (Fig.  202).     If  the 


Fig.  202. 


DigitJil  compression. 


thumb  is  used,  it  must  be  laid  flat  upon  the  vessel ;  in  either  case  the 
pressure  must  not  be  relaxed  ;  if  the  vessel  slips  from  the  grasp,  it 
should  be  instantly  compressed  again  upon  the  bone  by  the  fingers  or 


THE  PREVENTION  OF  HEMORRHAGE. 


739 


thumbs,  but  not  by  grasping-  tlie  linil) ;  the  fingers  are  best  employed 
in  compression  of  the  brachial,  the  radial,  and  the  ulnar  arteries ;  the 
thumb  in  compressing  the  carotid,  the  abdominal  aorta  against  the 
vertebne,  the  external  iliac  against  the  brim  of  the  pelvis,  the  femoral 
against  tlie  pubis,  or  against  the  femur  in  the  upper  part  of  the  thigii. 

The  key,  the  ring  being  so  ])addc(l  as  to  make  a  hard  mass,  is  used  to 
compress  deep-seated  arteries,  as  the  subclavian. 

The  tourniquet  has  several  modifications  (Fig.  203,  «,  h,  c),  but  the 
most  important  difference  is  in  the  efi'ect  upon  the  venous  circulation ; 
it  may  compress  the  limb  only  at  opposite  points  («)  or  the  entire 
limb,  the  pad  being  placed  over  the  artery  \b,  c).  The  most  useful 
instrument  is  that  in  common  use  {b).     In  its  application  it  is  usual 


Fig.  203. 


Fig.  204. 


Tourniquets. 


Tourniquet  applied. 


to  put  several  turns  of  a  roller  loosely  around  the  limb  at  a  point  where 
it  is  applied,  terminating  with  placing  the  cylinder  of  the  roller  over 
the  arterv  as  a  compress  ;  the  tourniquet  should  now  be  applied,  but  the 
screw  .should  not  be  placed  over  the  cylinder,  lest  the  liall  roll  from  the 
arterv  when  the  screw  is  worked.  The  screw  being  ])laced  at  one  side 
of  the  limb  (Fig.  204),  the  strap  should  be  buckled  tightly  and  the 
■screw  gradually  turned  to  the  nece-ssary  tightness.  If  the  point  of 
compression  of  the  arterv  admits,  put  the  cylinder  of  the  roller  between 
the  pad  and  the  strap  and  apply  it  directly  over  tlic  artery. 


Fig.  20'>. 


Tenaculum. 


Fig.  200. 


.\rtery  forceps. 


Ligation. — During  the  operation  tiic  hcinnrrhage  should  be  tempo- 
rarily controlled  by  .•seizing  the  bleetling  points  with  the  catch  forceps 
(Fig.  207),  and  allowing  them  to  remain  in  jxisitirm  until  the  oj)eration 
has  ])rocceded  so  i'ar  that  they  inu.-it  l)e  removed,  w  iicn  antiseptic  ligatures 
should  i)c  applied  to  each. 

In  aj)i)lying  the  ligature   to   large  arteries  the  coats  of  the  artery 


740 


OPERATIVE  SURGERY. 


slioiikl,  as  far  as  ])()ssil)l{',  be  isolated  from  the  surrouiiding  tissues.  On 
applyino;  the  ligature  make  the  surgeou's  knot  (Fig.  208)  or  the  reef 
knot  (Fig.  209). 

In  some  cases  the  lileeding  vessels  cannot  be  isolated,  and  it  becomes 


Fig.  207. 


Fig.  208. 


Siirf,'('<iirs  knot. 


Fig.  209. 


Catch-forceps. 


lWv(  knnt. 


necessary  to  enclose  a  small  area  with  a  ligature  (Fig.  210)  passed  around 
it  Avith  a  needle. 

Torsion. — The  twisting  of  an  artery  upon  its  axis  is  designed  to 
cause  laceration  of  the  internal  coats  ;  they  then  roll  into  the  calilire 
of  the  vessel   and   form  a  mesh,  within  which  a   blood-clot  forms  and 


Fig.  210. 


Fig.  211. 


Ent'lusing  tissues. 


Everted  end  of  innci  coals. 
Torsion  .applied. 


becomes  organized  ;  the  external  twisted  coat  remains  as  a  protection 
and  support.  Torsion  is  a  reliable  method,  especially  when  ap2)lied  to 
small  arteries,  but  is  not  generally  approved  for  large  arteries. 


THE  PREVENTION  OF  HEMORBHAQE. 


741 


Free  torsion  is  applicable  to  small  arteries,  and  consists  in  seizing  the 
extremity  of"  the  vessel  with  iirnily-united  forceps,  drawing  it  out  from 
its  connection,  and  rotating  it  several  times  (Fig.  211). 

Limited  torsion  is  applied  to  large  arteries,  as  follows:  Seize  the 
extremity  of  the  artery  with  strong  catch-forceps  luning  blunt  serra- 
tions ;  draw  it  well  out  of  its  sheath ;  grasp  it  firndy  with  a  second 
forceps  about  one  inch  from  the  end ;  now  rotate  the  first  forceps  three 
or  four  times  or  until  all  resistance  ceases. 

Acupressure. — Compression  of  the  artery  in  the  wound  by  means 
of  a  needle  (Simpson)  is  only  adapted  to  cases  in  whicli  the  artery 
cannot  be  seized  or  is  friable.  The  instruments  required  are  bayonet- 
pointed  pins  varying  in  length  from  three  to  five  inches,  with  glass  heads 
to  facilitate  their  introduction,  needles  threaded  with  iron  wire,  and  loops 
of  slender  annealed  iron  wire  five  or  six  inches  in  length.  On  the  cut 
surface  of  a  flap  tlie  ordinary  sewing  needle  answers  j)erf'ectly  well. 
There  are  several  metiiods  of  employing  the  pins  to  accomplish  com- 
pression, l>ut  they  may  be  reduced  to  three  (Fig.  213,  1,  2,  3),  and  will 
be  understood  by  the  illustrations. 

Acupressure  is  seldom  resorted  to,  as  with  antiseptics  it  has  no  advan- 
tage over  the  ligation,  exc^ejit  when  the  artery  cannot  otherwise  be  eon- 
trolled. 

Direct  compression  (Fig.  -12)  is  made  by  the  pin  thrust  through 
tile  flaj),  j)assed  over  tiie  artery,  and  brought  out 
of  the  integument  of  the  opposite  side  in  such 
manner  as  to  firndy  compress  the  mouth  of  the 
artery  against  the  muscle  upon  which  it  lies. 

Acupressure  by  forcejjs  (Allis)  is  an  inge- 
nious method  of  com])ressing  vessels  when  there 
is  much  oozing  from  surfaces  :  the  instrument 
consists  of  two  blades  (Figs.  214,  215)  under  the 
command  of  a  spring,  the  lower  of  which  is  a 
needle  and  designed  to  transfix  bleeding  tis- 
sues ;  which  done,  the  grasp  of  the  hand  is  released,  and  compression  is 
instantly  efl'ected  between  the  blunt  blade  which  lies  upon  the  surface  of 
the  bleeeling  vessels  and  the  needle  which  lies  beneath  them. 


Direct  acupressure. 


Fig.  213. 


Different  modes  of  niii>lying  acupressure. 


Cauterization. — The  cautery,  once  the  only  metliod  of  arresting 
bleeding  after  operations,  is  now  requii-ed  only  when  deep-seated  parts 
are  involved,  or  tissues  to  which  the  ligature  cannot  .safely  be  applied. 


742 


OPER.  1 TI VE  S  UR  CER  Y. 


Tlie  actual  cautery  consists  of  an  iron  or  steel  knob,  at  the  extremity 
of  a  long  shaft,  secured  to  a  handle  Tlie  shape  of  the  extremity  may  be 
round  or  pear-shaped,  or  flat   like  a   l)utton  ;  eacli   form   is  adapted  to 

special  conditions  rcquirinjr  its  use.  It 
may  be  heated  in  the  flame  of  a  spirit 
lamp ;  when  employed  to  arrest  hemor- 
rhage its  temperature  should  be  at  a 
dull    red    heat. 

Fic.  215. 


Acupressure  forceps. 


The  thermo-oanterii  (Fig.  217)  is  an  in.strument  by  which  a  high  de- 
gree of  heat  of  the  cautery  may  almost  instantly  lie  ol)tained,  and  may 
be  maintained  for  any  length  of  time  without  the  slightest  inconvenience. 


Fig.  216. 


C.  tIEMANN'CO. 


=« 


Cauteries. 


By  adapting  a  blade  to  it  dissections  may  be  made,  and  with  the  wire 
ccraseur  tumors  may  be  removed  in  a  l)lo<)dless  manner. 

Ligation  of  Arteries. — The  application  of  a  ligature  to  an  artery  can 
now  scarcely  be  considered  a  serious  operation,  for  when  the  antiseptic 


Fig.  217. 


Paquelin'.?  cautery. 

method  is  pursued  suppuration  does  not  occur,  and  if  the  proper  kind  of 
ligature  is  used  division  of  the  artery  docs  not  follow,  and  hence  there  is 
n(  I  danger  of  secondary  hemorrhage.  It  is  now  established  that  when  an 
artery  is  cli:)sed  by  an  aseptic  ligature  it  is  not  necessary  to  divide  the 
internal  coat,  but  only  to  press  its  opposing  surfaces  together  temporarily, 
to  secure  permanent  obliteration  of  its  canal.  In  this  process  the  intima 
becomes  covered  with  granulations;  these  unite  and  form  a  firm  union; 


THE  PREVENTION  OF  HEMORRHAGE. 


743 


also  new  tissue  fornis  around  the  ligature,  Hive  a  ring  of  callus,  strengtli- 
ening  the  point  of  ligation  ;  meantime  the  ligature  undergoes  absorption 
and  the  cure  is  complete.  By  the  antiseptic  operation  the  artery  is 
strengthened  at  the  seat  of  ligature,  and  there  can  be  no  danger  of  hem- 
orrhage. It  should,  however,  be  borne  in  mind  that  to  secure  the  best 
results  the  ligature  must  be  of  an  absorbable  nature;  for  ligatures  which 
permanently  resist  absorption  destroy  tlie  continuity  of  the  \-essel,  and, 
instead  of  adding  sti'ength  to  the  perivascular  cicatrix,  \\eaken  the  vessel- 
walls  at  the  seat  of  ligation. 

The  in.^fndiu'nty  required  are  a  scalpel,  force})s,  aneurism  needle,  liga- 
ture, director,  and  retractin's  or  spatulas.  Tiie  connnon  scalpel  is  best  adap- 
ted for  the  dissection,  and  the  broad  extremity  of  the  handli'  can  be  used 
to  advantage  in  separating  layers  of  fascia  and  parts  where  the  cutting  edge 
is  not  desirable  ;  the  dissecting  forceps  should  have  accurately  fitting  teeth, 
and  not  liable  to  open  at  the  extremity  when  firmly  closed ;  a  pair  of 
small  forceps  may  also  be  required.  The  aneurism  needle  is  a  curved 
blunt  instrument,  with  an  eye  near  the  extremity  and  firmly  fixed  in  a 
handle  (Fig.  21S).  When  used,  the  extremity  is  gently  insinuated  under 
the  vessel,  and  as  it  appears  upon  the  oppo- 
site side  the  loop  of  the  ligature  is  seized  Fif-  219. 
with  the  forceps  or  a  hook,  and,  one  end 
being  drawn  through,  it  is  held  as  the  in- 
strument is  withdrawn  carrying  the  other 
end,  and  thus  leaving  the  ligature  under 
the  vessel.  A  needle  well  adapted  to  those 
cases  where  the  artery  lies  deeply  consists 
of  the  handle  and  hook  (Fig.  220)  and  the 
l)lunt  needle  with  two  eves  (Fig.  219);  the 
needle  is  fitted  to  the  sliaft  (Fig.  220)  by  a  ^''?/|lti'ons^''P 
screw  ;  when  used,  the  ligature  is  inserted 
into  the  second  eye  ;  the  needle  is  then  passed  under  the 
artery,  and  as  the  extremity  emerges  upon  the  opposite 
side  the  hook  is  inserted  into  the  first  eye,  and  the 
needle  is  thus  held  until  the  handle  is  unscrewed,  when 
it  is  drawn  through  with  the  ligature.  It  is  sometimes 
necessary  to  include  other  tissues  with  the  arterv,  when 
the  sharj)-pointed  needle  (Fig.  219)  should  be  used.  The 
director  is  used  in  the  dissection  to  raise  the  fascia  before 
Aneurism  needle,  its  division  ;  it  is  Sometimes  passed  under  the  artery  as  a 
guide  to  the  needle.  Two  retractors  are  often  reciuired, 
with  which  assistants  separate  the  sides  of  the  wound  and  expose  the 
deci)-seated  parts ;  jneces  of  fiexihle  metal  or  wood  mav  be  used. 

The  aseptic  cafi/iif  or  Ki/l:iroriii-r/iit  Ihidiiirr  more  effectually  meets  the 
indications  present  than  other  kinds.  When  so  applied  as  not  to  sever  the 
tunics  of  the  ligate'd  vessel  it  is  gradually  displaced  bv  organized  tissue 
which  increases  the  resisting  capacity  of  the  vessel.  It  is  stated  that  the 
most  careful  microscopical  examinations  have  shown  that  catgut  increases 
to  a  considerable  extent  the  resisting  capacity  of  an  artery  in  forming 
firm  connective-tissue  connections  with  the  vessel.  It  follows  that  cat- 
gut ligature  should  be  ])referred,  and  that  it  is  onl}-  necessary  to  tie  with 
sufficient  force  to  approximate  the  inner  surflices  of  the  intima  with  a 


744 


OPERATIVE  SVnOERY. 


vi('w  to  ensure  effective  j)ro\isi()nal  ohiitenition,  when  cicatrization  will 
follow. 

Fig.  220. 


3b 


Artcry-hdok  and  handle  for  needle. 


The  operation  is  a,s  follows  :  Determine  the  precise  location  of  the 
artery — (1)  by  its  pulsation  ;  (2)  by  reference  to  anatomical  jioints  in  the 

vicinity.  To  render  tlie  former  dis- 
tinct, tile  liinl)  should  l)c  placed  in 
a  ])osition  favorable  to  arterial  cir- 
culation ;  to  render  muscles  and 
tendons  most  distinct,  the  limb 
should  be  forcibly  extended  at  the 
commencement  of  the  operation. 
A^^len  the  dissection  has  pnx'eeded 
so  far  as  to  reach  the  vicinity  of  the 
artery,  the  operator  is  aided  in 
detecting  its  position  by  flexing  tlie 
limb,  so  as  to  relax  the  muscles  and 
tissues.  Before  the  first  incision  is 
made  guard  against  wounding  supe- 
ficial  veins.  Their  position  is  readily 
defined  by  comjiressing  the  parts 
above  the  point  of  the  proposed 
operation.  When  the  first  incision 
is  about  to  be  made  the  skin  should 
be  rendered  tense  by  the  thumb 
and  forefinger  of  the  left  hand  ap- 
plied, one  on  either  side  of  ves.sel,  or  by  the  fingers  apjilied  at  the  extrem- 
ity of  the  proposed  incision  parallel  to  its  course :  if  the  first  metiiod  is 
chosen,  care  must  be  taken  mit  to  make  more  traction  on  one  side  than 
on  the  other.  The  second  method  answers  where  the  skin  is  naturally 
tense  and  but  slight  traction  is  necessary  ;  make  the  incision  directly 
over  and  parallel  to  the  artery,  through  the  skin  only  if  the  artery  is 
superficial,  but  also  through  the  cellular  tissues  if  it  is  deep,  its  length 
varying  with  the  depth  of  the  vessel  and  the  adipose  tissue.  Tlie  incision 
is  sometimes  made  in  the  direction  of  the  fibres  of  the  muscle  covering 
the  artery,  as  where  the  great  pectoral  overlies  the  axillary ;  at  other 
times  it  should  l)e  curved,  so  as  to  raise  a  flap. 

The  length  of  the  incision  cannot  be  prescribed,  but  it  should  always 
be  ample.  Pinch  up  the  fascia  carefully  with  the  forcejjs  (Fig.  221) ; 
nick  it  M'ith  the  scalpel  applied  horizontally  ;  incise  freely  on  a  director 
introduced  beneath.  In  dissecting  amony;  muscular  structures  enter 
the  muscular  interstices  and  do  not  wound  the  substance.  These  inter- 
muscular spaces  are  marked  by  deposits  of  fat,  esjiecially  toward  the 
terminal  extremity  of  the  muscles,  and  hence  we  should  commence  the  sep- 
aration of  muscles  as  nearly  as  possible  at  their  terminal  extremity.  If  there 
is  doubt  as  to  the  line  of  separation,  a  puncture  will  disclose  adipose  or 


Opening  the  sheath. 


THE  PREVEXTION  OF  HEMORRHAGE. 


745 


miisfulai-  tissue,  aceoriling  to  the  nature  of  tlie  underlying  structure.  If 
the  dissection  is  made  througii  the  body  of  the  muscle,  the  fibres  separate 
more  readilv  in  an  inverse  direction — namely,  from  their  origin  to  their 
attachments.  The  muscles  may  be  separated  witli  the  handle  of  the 
scalpel  or  the   tinger-nail. 

The  larger  arteries  have  firm  sheaths,  which  reijuire  to  l)e  opened  by 
dissection  ;  the   smaller  vessels  have  but  slight   investments,   and  are 


Fig.  222. 


Fio.  223. 


Passing  tlie  needle:  first  stage. 


Passing  the  needle  :  second  stage. 


readily  exposed  with  the  jioint  of  a  director  or  the  aneurism  needle. 
The  sheath  is  opened  by  pinching  up  a  small  jjortion  with  the  forceps  and 
nicking  it  slightly  with  the  scalpel  ;  into  the  opening  thus  made  intro- 
duce the  point  of  the  needle  (Fig.  222) ;  by  slight  movements  of  its 
point,  first  uiion  one  side  and  then  upon  the  other,  separate  the  sheath 
completely  around  the  vessel  to  an  extent  sufficient  to  allow  simply  the 
passage  of  the  ligature ;  as  the  extremity  of  the  instrument  emerges  on 
the  opposite  side,  with  the  finger  of  the  left  hand  or  the  thumb  and  fore- 
finger pressed  together  steady  its  jioint  as  it  penetrates  the  last  portion 
of  the  sheath.  If  the  artery  is  small  and  very  superficial,  a  director  may 
be  passed  under  and  along  its  groove,  a  l)lunt  needle  carrying  the  liga- 
ture. If  more  deeply  situated,  the  common  aneurism  needle  (Fig.  218) 
or  the  doul)le-eye  needle  (Fig.  219),  should  be  used.  The  point  of  the 
needle,  gently  moved  laterally,  aids  materially  in  separating  the  artery 
fi-oni  the  sheath  (Fig.  223).  The  needle  should  be  passed  from  the 
veins ;  no  force  should  be  used,  lest  the  instrument  penetrate  the  coats 
of  tlie  artery. 

The  ligature  should  l)e  ])laced  at  a  right  angle  with  the  long  axis  of 
a  vessel,  and  the  reef-knot  (Fig.  2(l!>)  tied  unless  there  are  special  reasons 
for  adopting  the  surgeon's  knot  (Fig.  20S).  The  first  knot  is  tightened 
around  the  vcs.sels  firmly,  on  either  side  of  the  ligature,  near  the  artery, 
with  the  index  fingers  carried  to  the  bottom  of  the  wound  (Fig.  224). 
The  decree  of  constriction  varies  with  the  size  of  the  arteries,  but  it 


746 


OriiRATIVE  SURGERY. 


Fig.  224. 


need  not  be  so  great  as  to  rujitiirc  tlie  internal  coats.     In  tyin<i:  tlie  second 
knot  care  must  be  taken  not  to  tiglitcn  the  thread  firndy  until  traction 

is  made  on  a  ])lane  witii  the  first  knot, 
with  the  fingers  again  carried  down  to 
the  vessel.  The  two  ends  of  the  liga- 
ture must  be  cut  not  too  near  the  knot. 
TIk^  dressimi  of  the  tvound  should  l)c 
strictly  antisejitic  for  the  ])urj)osc  of  se- 
curing inunediate  union.  A  catgut  drain 
should  be  placed  in  the  lowest  angle. 
The  deeper  .structures  may  first  be 
stitched  with  the  continuous  catgut  su- 
ture ;  then,  if  the  MOund  is  large,  two 
or  three  deep  sutures  of  relaxation  may 
be  inserted.  Close  the  cutaneous  wound 
with  the  continuous  or  interrupted  su- 
ture. Complete  the  dressing  Ijy  antiseptically  cleaning  the  external  sur- 
face, dusting  it  with  iodoform,  and  applying  the  iodoform  gauze  or  a 
bandage  of  bichloride  gauze. 


Tying  the  knot. 


ARTERIES    OF    THE    THORAX,    NECK,    AND    HEAD. 

The  innominate  artery  is  in  relation  on  the  right  with  the  pleura,  right 
vena  innominata,  and  right  pneumogastric  nerve ;  behind,  with  the 
trachea ;  on  the  left,  with  the  left  carotid ;  in  front,  above,  with  the 
sternum  and  the  origin  of  the  sterno-hyoid  and  thyroid;  Ix'low,  with  tiie 
inferior  thyroid  vein  and  left  vena  innominata. 

Operation. — Place  the  patient  on  the  back,  with  the  shoulders  .slightly 
raised,  the  right  arm  drawn  downward,  and  face  turned  to  the  opposite 

side  ;  make  an  incision  three  inches  in 
Fig.  225.  length  just   above    the    clavicle)   ter- 

minating over  the  trachea,  and,  if  re- 
(piired,  a  second  of  the  same  length 
from  this  point  along  the  inner  bor- 
der of  the  sterno-mastoid ;  divide  the 
^       ^s^'ffev  sternal  and  part  of  the  clavicular  por- 

j ^. -----^i^P  ?'^^k  *^'^'"  ^'^  ^'^^  sterno-mastoid  (Fig.  225,  e) 

^.■;^.flir.I-~:.".~~v:""/-:^l^^ffV  on  a  director  and  turn  out\\-ard  ;  divide 

« -^^"^93^^^        the  sterno-hyoid  and    thyroid    in   the 

(  same  manner ;  draw  them  inward,  ex- 

posing the  sheath  of  the  carotid,  par 
vagum,  and  internal  jugular  vein  ;  now 
Innominate  artery.  Separate  the  par  vagum,  b,  from    tiie 

carotid  ;  draw  the  vein,  c,  to  the  out- 
side, and  the  artery  toward  the  trachea,  and  expose  the  subclavian  ;  the 
innominate  artery,  (J,  is  now  uncovered  ;  pass  the  needle  from  below 
upward  and  inward  ;  care  is  necessary  to  avoid  wounding  the  pleura 
behind. 

The  sitbclarian  and  common,  carotid  arteries  (Fig.  226)  may  be  ligated 
by  the  following  operation  :  Place  the  patient  in  the  position  for  ligature 
of  the  innominate ;  make  an  incision  three  inches  in  length  through  the 


LIGATURE  OF  ARTERIES. 


747 


integuments,  along  the  space  separating  the  clavicular  and  sternal  attach- 
ments of  the  sterno-cleido-mastoid  muscle ;  tliis  interval  is  marked  by  a 
depression  above    the   clavicle  at  the 

articulation  of"  the  clavicle  and  ster-  Fio-  226. 

num  ;  flex  the  head  ;  slightly  separate  I 

the  internal  portion  of  the  nuisclc,  a,  I 

from  the  external,  b  ;  divide  tiie  sterno-  ^//          ^sk. 

hyoid  and  thyroid  on  the  director.  The  ^  13Z"^;;Z!!^.'".f.        ^^rt>^\  ^1 

innominate,  h  ;  tiie  common  carotid,  c  ;    '■  '~"yz,i /"'     ii£ "Ull  '''^^  '  • 

the  pneumogastric,  f7,  and  its  branch,  /         ^^a»*^'°'^"4€ll  ll     ^    i 

the  recurrent  laiyngeal ;  the  origin  of  '^ Z".V.'Z\'.'-.'^^...--^^r\  jfi  '''Xf^'"^ 

the  subclavian,  //,  and  its  branches,  the    •'  " Wit  >       ! 

vertebral,  c,  and  inferior  thvroid,  are    '» "^r^^- b-^-^ 

now  un<ler  control.  y     nT^V  /      ^ 

The  common  carotid  arteries  extend  ^''              \cj 

on  the  right  side  from  the  innominate,       subclavian  and  common  carotid  arteries. 

and  on  the  left  from  the  highest  point 

of  the  arch  of  the  aorta,  to  the  upper  border  of  the  thyroid  cartilage ; 
the  direction  is  obliquely  from  before  backward,  and  from  within  out- 
ward, along  the  external  side  of  the  trachea  and  larynx,  in  a  line  drawn 
from  the  sternal  end  of  the  clavicle  below  to  a  point  midway  between 
the  mastoid  process  and  angle  of  the  jaw  above.  The  sheath  is  derived 
from  the  deej)  fascia,  and  contains  the  internal  jugular  vein  and  the 
pneumogastric  nerve,  the  vein  being  externtd  and  the  nerve  between. 
(«)  At  the  base  of  the  neck  the  artery  is  deeply  seated.  The  carotid 
tubercle  is  a  guide  to  the  position  of  the  artery  ;  this  tubercle  is  the 
anterior  projection  of  the  transverse  process  of  the  sixth  cervical  vertebra, 
which  is  two  inches  above  the  clavicle,  and  is  a  precise  guide  to  the 
ai-tery  when  the  neck  is  sti-aight ;  it  corresponds  in  front  and  a  little  inside 
to  the  artery  (Fig.  227).     The  patient  being  in  the  recumbent  position, 

Fig.  227.      . 

) 


Common  carotid  ;  first  part. 


the  head  extended  and  inclined  to  the  opposite  side,  recognize  the  inter- 
val between  the  two  attachments  of  the  sterno-mastoid  muscle,  and  make 
an  incision  from  the  clavicle,  two  and  a  half  inches,  obliquely  along  this 
interspace  ;  divide  the  skin,  ])latysina,  an<l  deep  fascia  ;  draw  the  internal 
portion  of  the  muscle,  c,  inward,  and  tiie  external,  a,  outward,  by  means 
of  spatulas;    this  exposes    the  internal   jugidar  vein,  b,  the   pneumo- 


748 


orjJIiA  TI VE  SUIWEB Y. 


gastric  nerve,  c,  lying  hotwcon  tlio  vein,  h,  and  tlie  artery,  /,  and  the 
(inio-liyoid  muscle,  (/,  crossing  tlic  upper  part  of  the  wound  ;  open  the 
sheath  and  pass  the  needle  from  without  inward,  carefully  avoiding  tlie 
internal  jugular  vein  and  par  vagum  ;  a  linger  pressed  upon  the  vein  at 
the  upper  part  of  the  wound  will  cause  it  to  collapse. 

{J))  Below  the  omo-hyoid   the  artery  is  much  more  accessible  (Fig. 
228).     Place  the  patient  on  the  back,  with  the  head  thrown  back  ;  make 


d  the 


Fig.  2l!9. 


Common  carotid  below  omo-hyoid. 

an  incision  three  inches  in  length  along  the  inner  border  of  the  sterno- 
mastoid  mnscle,  in  the  line  above  given,  terminating  at  the  top  of  the 
sternum  ;  successively  divide  the  skin,  superficial  fascia,  platysma,  and 
dec])  fascia,  and  expose  tlie  inner  border  of  the  sterno-niastoid,  v  ;  care- 
fully avoid  the  steriio-iiiastoid  artery  and  middle  thyroid  vein  ;  throw 
the  head  forward  and  draw  the  stcruo-mastoid  muscle  outward 
stcrno-hyoid  and  thyroid  mu.scles  inward  ;  expose 
the  anterior  belly  of  the  omo-hyoid  muscle,  a,  which 
should  be  drawn  upward  ;  divide  the  deep  ftiscia  ; 
expose  the  sheath  of  the  vessel  ;  open  it  directly 
over  the  artery,  avoiding  carefully  the  dcscendens 
noni,  which  runs  along  the  tracheal  side  ;  press  the 
pneumogastric  nerve,  il,  and  internal  jugular  vein, 
c,  outward,  and  pass  the  needle  from  M'ithout  in- 
ward, carefully  isolating  the  vessel  from  the  infe- 
rior thyroid  artery  and  recurrent  laryngeal  nerve 
which  lies  behind  it. 

(c)  Above  the  omo-hyoid  the  artery  is  still 
more  snperficial,  being  covered  only  by  the 
skin,  the  two  fasciae,  platysma,  and  the  border  of 
the  sterno-mastoid  ;  it  is  in  relation  internally 
with  the  larynx  and  pharynx,  and  externally 
with  the  jincumogastric  nerve  and  internal  jugu- 
lar vein  {Fig.  229).  Place  the  patient  on  the 
back,  the  shoulders  raised  and  the  head  turned  to 
the  opposite  side  ;  make  an  incision  from  a  little 
below  the  angle  of  the  jaw,  in  the  line  given, 
along  the  internal  border  of  the  sterno-mastoid, 
three  inches  in  length  ;  di\ide  the  integuments,  superficial  fascia,  and 
platysma ;  raise  the  deep  fascia  cai'efully  on  a  director ;  avoid  the  small 


Right  common  carotid  ar- 
tery at  the  seat  of  liga- 
ture: pi,  platy.sma;  ,»!.  m, 
sterno-mastoid,  drawn  to 
one  side ;  o.  A,  omo-hyoid. 
drawn  downward  and  in- 
ward :  *■.  h,  sterno-hyoid ; 
a,  the  artery ;  v,  internal 
jugular  vein  ;  d.n.n,  de- 
"scendens  noni  nerve.  The 
pneumogastric  is  not  seen, 
as  it  lies  behind  the  ves- 
sels. 


LIGATURE  OF  ARTERIES. 


749 


underlving-  veiiiir ;  flex  the  head  to  relax  tlie  nuiseles,  and  draw  tlie  wound 
apart  l)y  .sj)atuhe ;  avoid  the  descendeas  iioni  nerve  and  superior  thyroid 
arteries,  and  open  the  sheath  over  the  artery  ;  if  the  internal  jugular 
vein  swell  up  into  the  wound,  compress  it  in  the  upper  and  lower  jjarts 
of  the  wound,  and  draw  it  outward ;  pass  the  ligature  from  without 
inward,  the  point  of  the  needle  lieing  kept  close  upon  the  artery,  to 
avoid  wounding  the  vein  or  ineluding  the  pneuniogastric  nerve  (Fig.  2."]0). 
The  external  and  infernal  carofidn  arise  from  the  common  trunk  at 
the   upfier  border  of  the  thyroid   cartilage,  the    external    being   more 

Fig.  230. 

Pueumogastric  nerve. 


.Tiigular  vein ;  venous  compartment  of 
sheath,  the  part  to  be  avoided. 


Carotid  artery,  sliowing  arterial 
compartment  of  sheatii.  An 
arrow  indicates  the  part  to  be 
opened. 


Diagram  of  the  carotid  sheath  (Sir  W.  llacCurmac). 

.superficial  than  the  internal  at  their  origins.  ^Take  an  incision  along  the 
inner  luai'giu  of  the  sterno-niastoid,  three  inches  in  length,  from  the 
angle  of  the  jaw  to  the  cricoid  cartilage,  through  the  skin,  platysma, 
superficial  and  deep  fascia ;  the  internal  margin  of  the  sterno-mastoid 
now  appears;  cautiously  separate  the  cellular  tissue,  and,  the  wound 
being  drawn  apart,  the  external  carotid  artery  is  exposed  ;  draw  the 
digastric  muscle  and  hypoglos.sal  nerve  upward  and  the  internal  jugu- 
lar outward  ;  both  arteries  may  now  be  ligated,  or  either  artery  sei)aratelv. 

The  external  carotid,  artery  ascends  from  its  origin  at  first  sligiitly 
forward,  then  backward,  to  the  space  between  the  condyle  of  the  lower 
jaw  and  the  meatus  auditorius  ;  above  the  digastric  the  arterv  lies  more 
deeply  and  is  crtKs.sed  by  the  stylo-hyoid  nuisele.  Make  an  incision  from 
near  the  angle  of  the  jaw  to  tlie  middle  of  the  thyroid  cartilage,  along 
the  inner  margin  of  the  sterno-mastoid,  about  three  inches  ;  divide  the 
skin,  platysma,  and  fascia;  seek  with  the  linger  the  tip  of  tiie  great 
cornu  of  the  hyoid  bone. 

The  superior  thyroid  artery  arises  from  the  external  carotid,  just 
l)el(iw  the  greater  cornu  of  the  hyoid  bone,  and  passes  inward  to  the 
thyroid  gland  in  a  tortuous  course.  Place  the  head  in  an  extended 
position  ;  make  an  inoision  an  inch  and  a  half  along  the  internal  border 
of  the  sterno-mastoid,  the  centre  of  which  corresponds  to  the  great  cornu 
of  the  thyroid  cartilage  ;  incise  the;  skin  anil  platysma  ;  draw  the  sterno- 
mastoid  outward  and  expose  the  omo-hyoid  nuiscle,  internal  jugidar 
vein,  and  primitive  carotid  artery  ;  the  artery  lies  between  these  vessels 
and  the  IoIk'  of  the  thyroid  body  ;  ])ass  the  needle  from  aliove  downward 
with  the  point  inclined  to  tlie  thyroid  Ixidv. 

The  lingual  artery  (Fig.  232),  the  secontl  branch  of  the  external  caro- 


750 


OPERATIVE  SURG  EI!  V. 


tid,  nriscs  just  above  tlic  superior  tliyroid,  aseeiids  to  tlie  <rreat  cornu  of 
the  liyoid  hone,  runs  ])arallel  with  it  and  passes  inward  on  the  middle 
constrictor  and  jicnio-hyoirlossns  to  the  outer  edge  ol'  the  hvoglossus 
muscle  ;  it  tlien  passes  upward  and  inward  beneath  the  digastric,  stylo- 
hyoid, and  hyoglossus  muscles  to  the  base  of  the  tongue.  The  artery 
passes  througii  three  regions:  (1)  external  to  the  hyoglossus  muscle,  (2) 
beneath  the  muscle,  (3)  from  its  inner  margin  to  the  tip  of  the  tongue  ; 
the  second  ))orti<jn  is  selected  for  ligation.  Turn  tlie  iiead  to  the  oppo- 
site side;  make  an  oblique  incision  an  inch  and  a  half  in  length,  a  little 
above  the  body  of  the  hyoid  bone,  and  j)arallcl  with  it,  near  the  median 
line,  and  curved  backward,  outward,  and  downward,  ])arallel  with  the 
sujjerior  border  of  the  great  cornu  of  the  thyroid  cartilage  (Fig.  231) ; 

Fig.  231. 


Lines  of  incision  for  ligature  of  tlie  first  part  of  the  axillary  artery,  the  third  part 
of  the  subclavian,  the  common  carotid,  and  the  lingual. 

divide  the  superficial  parts,  and  with  the  finger  recognize  the  direction 
of  the  great  cornu  ;  divide  uj)on  it  the  aponeurosis  which  covers  the  deep 
parts ;  this  e.xposes  the  digastric  muscle,  the  submaxillary  gland,  hypo- 
glossal nerve,  and  stylo-hyoid  muscle  ;  now  isolate  the  great  cornu  of  the 
hyoid  bone,  and  the  fibres  of  the  hyoglossus  muscle,  \vhich  are  attached 
at  this  point,  come  into  vic\\' ;  divide  this  muscle  at  the  superior  border 
of  the  great  cornu  ;  draw  it  upward  and  backward,  and  the  artery  is 
found  l)ehin(l  it  ;  the  needle  should  pass  from  above  downward. 

The  fiiridi  (irterij  (Fig.  2-32)  arises  a  little  above  the  lingual,  is  iirst 
directed  obliquely  forward  and  upward  beneath  the  base  of  the  maxil- 
lary bone,  where  it  changes  its  direction  and  pas,ses  up^vard  over  the 
base  of  the  lower  maxilla  in  front  of  the  masseter  muscle.  It  consists 
of  a  cervical  and  facial  jjortion  :  the  first  is  comparatively  superficial, 
being  covered  only  by  the  jilatysma  and  fascia,  is  crossed  by  the  digas- 
tric and  stylo-hyoid  muscles,  and  then  enters  the  submaxillary  gland. 
Emerging  from  the  gland,  the  second  part  turns  over  the  jaw,  covered 


LIGATURE  OF  ARTERIES. 


751 


bv  the  platvsma  and  fascia,  and  ascends  to  the  inner  canthus  of  the  eye. 
In  the  first  part  nialve  an  incision  similar  to  that  for  exposing  the  lingual 
arterj',  but  nearer  tlie  base  of  the  jaw ;  incise  the  skin  and  tissues  over 

Fic.  232. 

Facial  vein. 

f,-.        Masvter.  / 


Mi/I't  liyoid. 
.        .         \        ('  Ijigastric. 

\l.iiigual\  \     Ui  liyuides. 

art.\        Lingual  vein. 
Hypuglussai  nei've. 

Siylu-hyoid. 

Int.jugiilar. 
Auatomicjil  relations  of  the  lingual  and  facial  arteries  (Tillaux). 

the  submaxillary  gland  ;  draw  the  gland  ujnvard,  and  the  artery  will  also 
l)e  raised,  when  it  can  he  easily  separated  from  the  vein  and  ligated. 
In  tlic  second  part  (Fig.  2.3.3)  recognize  at  the  junction  of  the  posterior 
third  with  the  anterior  two-thirds  of  the  body  of  the  bone  the  pulsation 

Flo.  233. 


The  facial  and  temporal  arteries 


of  the  artery ;  make  an  incision  an  inch  in  length  along  the  course  of 
the  vessel,  as  already,  given,  through  the  skin,  fascia,  and  platvsma  ;  the 
wound  being  separated  and  the  til)rous  tissue  divided,  the  artery,  c,  is 


752 


OPERATIVE  SURGERY. 


exposed,  and  tlie  vein,  J),  and  nia.sseter  muscle,  <(,  are  drawn  outward  and 
the  needle  passed. 

The  icmpond  artcrt/  (Fig.  2'V-V)  runs  u|)ward  toward  the  temporal 
region  from  its  origin  at  the  condyle  of  the  jaw,  in  front  of  the  concha  ; 
two  inches  above  the  zygoma  it  divides  into  the  anterior  and  posterior 
branches.  Recognizing  the  jiosition  of  the  artery  by  its  pulsation,  at  a 
point  above  the  zygomatic  arch  and  in  front  of  the  ear  make  an  incision 
through  the  skin  an  inch  in  length;  divide  the  dense  cellular  tissue  on 
a  director,  and  the  artery,  a,  will  be  exjwsed  ;  pass  the  needle  from 
behind  forward  to  avoiil  the  temporal  vein,  b,  and  the  auriculo-tem- 
poral  nerve. 

The  middle  incniiH/c(d  artcri/  is  the  largest  branch  of  the  internal 
maxillary  and  the  largest  artery  which  sup}>lics  the  dura  mater.  It 
ascends  under  the  external  pterygoid  muscle,  and  enters  the  skull 
through  the  sjnnous  foramen  of  the  sphenoid  bone  ;  within  the  skull 
it  passes  beneath  the  dura  mater  to  the  middle  fossa,  where  it  divides 
into  two  terminal  bi'anches ;  the  anterior,  the  larger,  passes  upward  on 
the  great  wing  of  the  sjihenoid  in  a  deep  groove  in  the  anterior  inferior 
angle  of  the  parietal  bone,  where  it  divides.  This  division  may  be 
ligated  for  intracranial  hemorrhage.  The  artery  is  most  accessible 
where  it  crosses  tiie  anterior  inferior  angle  of  the  jiarietal  bone.  De- 
termine the  position  of  the  artery  by  the  intersection  of  a  horizontal 
line  drawn  two  inches  above  and  parallel  ti)  the  zygoma,  M'ith  a  vertical 
die  an  inch  behind  the  posterior  sujjerior  border  of  the  malar  bone; 
make  a  crucial  incision  througii  the  skin,  <lividc  the  temporal  muscle, 
and  expose  the  skull  ;  the  bone  is  unerjually  thick  in  this  region,  and 
care  must  be  taken  in  using  the  tre|)hine ;  the  circle  of  bone  being 
removed,  the  bleeding  vessel  may  be  ligated  or  pressure  may  be  employed 
to  arrest  hemorrhage. 

The  occipital  artevy  arises  from  the  posterior  part  of  the  external 
carotid,  opposite  or  a  little  above  the  facial,  ascends  beneath  the  poste- 
rior belly  of  the  digastric  muscle  to  the  space  between  the  transverse 

process  of  the  atlas  and  the  mastoid 
process,  and  is  distributed  to  the  o(^cip- 
ital  region. 

At  its  origin  the  artery  is  covered  by 
the  stylo-hyoid  and  digastric  nniscles, 
and  the  hvjioglossal  nerve  winds  around 
it  from  behind  forward.  Make  an  in- 
cision along  the  inner  border  of  the 
sterno-mastoid  muscle,  two  inches  in 
length,  at  the  angle  formed  by  this  mus- 
cle and  the  digastric ;  the  deep  fascia 
being  carefully  divided,  expose  and  iso- 
late the  artery,  the  nerve  being  pro- 
tected. 

Behind  the  mastoid  process  (Fig. 
234)  the  artery  passes  upward  in  a  tor- 
tuous direction,  and  divides  into  branches 
upon  the  occiput  ;  it  is  covered  by  the  sterno-mastoid  and  splenius  mus- 
cles.    Make  an  incision,  one  inch  long,  half  an  inch  behind,  and  a  little 


Occipital  artery. 


LIGATURE  OF  ARTERIES.  753 

beneath  the  mastoid  process,  obliquely  upward  and  backward ;  divide 
the  skin  and  aponeiu\>sis  of  the  sterno-mastoid  muscle,  c,  as  also  the 
splenius  muscle,  through  the  whole  lengtii  of  the  wound  ;  the  pulsations 
of  the  artery,  a,  are  recognized  by  the  finger  a  little  above  the  obliipie 
muscle,  6,  and  it  is  isolated  from  its  veins. 

The  posterior  attriciilar  artery  arises  in  the  parotid  glanil  nearly  oppo- 
site the  apex  of  the  mastoid  process ;  it  ascends  to  the  interval  between 
the  mastoid  process  and  external  auditory  meatus,  where  it  divides. 
Make  a  vertical  incision  midway  between  the  two  points  above  given  ; 
the  pulsations  of  tiie  artery  will  prove  the  immediate  guide  for  its 
ligation. 

The  internal  carotid  artery  continues  directly  upward  from  the  ter- 
mination of  the  common  carotid,  opposite  the  upper  border  of  the  thyroid 
cartilage  to  the  carotid  foramen  of  the  temporal  bone;  at  first  it  is 
covered  onlv  by  the  sterno-mastoid  muscle,  platysma  myoides,  and 
fascia  ;  it  lies  to  the  outer  side  tif  the  external  carotid.  ]\Iake  the  same 
incision  as  for  the  common  trunk,  its  centre  being  one-half  to  three- 
quarters  of  an  inch  above  the  ui)per  border  of  the  thyroid  cartilage; 
veins  will  be  met  with  which  must  be  a\oided  or  tied  ;  tiie  descendens 
noni  nerve  runs  along  the  artery,  and  the  hypoglossal  crosses  it  about 
one  inch  from  its  bife.rcation.  First  find  the  external  carotid,  and  draw 
it  inward.  Pass  the  needle  from  the  outer  side,  carefully  avoiding  the 
jugidar  vein  and  pneumogastric  ner\-e  externally,  the  hypoglossal  nerve 
suix'rficially,  and  the  external  carotid  internally. 

The  internal  mammary  artery  arises  from  the  subclavian  on  its  lower 
and  anterior  })art,  opposite  the  tliyrt)id  axis  and  close  to  the  anterior 
margin  of  the  scalenus  anticus  ;  it  runs  directly  downward  and  slightly 
inward  beliind  the  clavicle  on  the  inner  surface  of  the  costal  cartilages 
near  the  sternum.  The  internal  jugular  and  snliclavian  veins  and  the 
phrenic  nerve  cross  the  upper  part ;  in  the  chest  it  at  first  lies  on  the 
costal  cartilages  and  intercostal  muscles,  covered  by  the  pleura  behind  ; 
but  lower  it  is  covered  also  by  the  triangularis  sterni  muscle.  It  may  be 
tied  in  the  second,  tliird,  or  fourth  intercostal  spaces.  Make  an  incision 
along  tile  upper  edge  of  the  costal  cartilage,  connnencing  at  the  sternum, 
in  either  space,  slightly  upward  and  outward,  an  inch  and  a  half  in 
length ;  divide  the  skin,  cellular  tissue,  pectoralis  major  muscle,  fascia, 
and  intercostal  muscle  successively ;  a  thin  layer  of  cellular  tissue  is 
exposed,  which  conceals  the  ai'tery  ;  pass  the  needle  cautiously  from 
within  outward. 

Tiie  vertebral  artery  (Fig.  235)  arises  from  the  upper  and  l)ack  ])art 
of  the  subclavian  artery  in  the  first  part  of  its  course,  about  one-third 
of  an  inch  internal  to  the  inner  border  of  the  scalenus  anticus  muscle, 
and  passes  directly  along  the  spinal  column  to  the  foramen  in  the  trans- 
verse process  of  the  sixth  cervical  vertebra,  and  then  ascends  through 
tile  series  of  foramina  of  the  transverse  jirocesses  to  the  cavity  of  the 
cranium.  Before  enteriiig  tiie  vi'rtel)ral  canal  tiie  artery  passes  l)cliind 
the  internal  jugular  vein  and  inferior  thyroid  artery  to  the  sjiine,  where 
it  lies  between  the  scalenus  anticus  and  longus  colli,  and  in  a  line  drawn 
from  tlie  posterior  part  of  the  mastoid  jirocess  to  the  junction  of  the 
internal  fourth  with  the  external  three-fourths  of  the  clavicle.  Place 
the  ])atient  on  the  liack,  the  shoulder  depressed,  and  the  head  turned  to 
Vol.  I.— 18 


■54 


OPERA  TIVK  SURGER Y. 


tlie  opposite  side;  make  an  incision  tln'ci'  inclios  in  luni^tli  from  tiie 
claviclo  along  tiie  outer  border  of  the  sterno-niastoid  muscle  ;  divide  the 
the  skin,  and  cellular  tissue  ;  bring  into  view  the  common  sheath  of  the 


Fig.  28o. 


*-  u  H  » 

Anatomy  of  the  vertebral  iiml  inferior  thyroid  arteries  (from  Treves):  yl,  thyroid  gland;  ;;.  tra- 
chea: C,  clavicle;  _/>,  strrnuthyroid;  A',  scalenus  medins  ;  /'.  longus  colli,  with  symi»atlie1ic 
nerve  upon  it;  G,  scalenus  :inticus  (cut):  if,  subclavius ;  /.transverse  yjrocess  of  the  sixth 
cervical  vertebra:  7.  l>r;ielii;il  jilexus;  a.  left  innominate  vein,  receiviiiir  internal  jugular:/j. 
ju,£rular  vein,  entering  sulu-bnian  vein:  c,  eommmi  carotid  artery,  with  vagus  nerve  to  its 
inner  side  ;  rf,  subclavian  ai-teiy  crossed  by  ner\ e  to  subclavius  :  f.  vertebral  artery  and  vein  ; 
,/,  inferior  thyroid  artery. 

carotid,  the  internal  jugular,  ;uid  the  pncumogastrie  nerve ;  separate 
with  the  finger  the  cellular  connection  of  the  sheath  with  the  sterno- 
thyroid muscle,  and  finally  with  the  longus  colli  ;  the  head  is  now  rai.sed, 
though  still  turned  t<i  the  o))posite  side,  and  the  sides  of  the  wound 
forcilily  .'<c]>aratc(l  ;  divide  the  cellular  tissue  at  the  bottom,  and  expose 
an  aponeurosis  which  })as.ses  from  the  scalenus  anticus  to  the  longus  colli 
and  the  anterior  part  of  the  transverse  process  of  the  sixth  cervical 
vertebra,  the  carotid  tubercle ;  then  open  the  ajioneurosis  an  inch  below 
this  point  at  the  external  border  of  the  longus  colli  muscle  ;  the  artery 
is  exposed  verj-  dee})ly  situated. 

The  inferior  flii/roiil  arferi/  (Fig.  235)  is  a  branch  of  the  thyroid  axis  ; 
it  ascends  the  neck  obliquely,  passing  behind  the  internal  jugular,  the 
pncumogastrie  nerve,  the  carotid  artery,  and  omo-hyoid  muscle  to  the 
thyroid  body.  On  the  left  side  it  lies  on  the  oesophagus,  and  the  thoracic 
duct  is  at  first  posterior,  and  afterward  arches  over  it  in  front  of  the 
artery  to  the  left  suljclavian  vein  ;  near  tlie  gland  the  recurrent  laryngeal 
nerve  often  passes  l)etwecn  its  terminal  l)ranehcs.  Make  the  same  incis- 
ion as  for  the  ligature  of  the  common  carotid  (Fig.  227).  When  its 
sheath  is  reached,  draw  it  outward  ;  the  artery  crosses  obliquely  inward 
opposite  this  point ;  when  the  vessel  is  fully  exposed  ajiply  tlie  ligature 
as  near  the  carotid  as  you  can  to  avoid  the  recurrent  laryngeal  nerve. 


ARTERIES  OF  THE  UPPER  LIMB. 


The  subclavian  artery  arises  from  the  innominate  on  the  right  side, 
and  from  the  arch  of  the  aorta  on  the  left ;  it  extends  in  a  curved  direc- 


LIGATURE  OF  ARTERIES.  755 

tion  from  its  origin  to  the  lower  border  of  the  first  rib.  It  may  be 
lio-ateil  ill  three  places — viz.  inside,  between,  and  outside  the  scaleni 
nm.scles ;  the  latter  location  is  always  to  be  preferred,  and  will  be 
described.     Outside  of  the  scaleni  muscles  (Fig.  236)  the  artery  passes 


Ligature  (if  the  right  subclaTJan  (third  part)  (from  Treves):  J,  clavicle;  B,  sterno-mastoid ;  C', 
trapezius;  D,  omo-hvoid;  E,  anterior  scalena;  F,  cervical  fascia;  a.  subclavian  artery;  6, 
subclavian  vein  ;  c,  cxt.  jugular  vein  ;  d,  transverse  cervical  artery  ;  1,  brachial  plexus. 

downward  and  outward,  lying  in  a  groove  on  the  first  rib.  It  first 
passes  through  the  supra-clavicular  triangle,  and  is  then  covered  only 
by  the  deep  fascia,  the  ])latysnia,  and  skin  ;  lower  in  its  course  it  is 
covered  by  the  clavicle  and  sulx'laviaii  muscle  ;  the  subclavian  vein  lies 
lower  and  in  front  of  the  artery,  separated  from  it  by  the  insertion  of 
the  scalenus  anticus  muscle ;  the  external  jugular  vein  crosses  in  front 
of  the  artery  ;  the  brachial  plexus  of  nerves  lies  above  and  behind  the 
artery.  The  depth  of  the  artery  may  vary  from  one  to  three  inches, 
according  to  the  depth  of  fat.  Search  for  the  artery  in  the  supra- 
clavicular triangle,  which  is  bounded  externally  by  the  omo-hvoid 
nuisclc,  internally  by  the  scalenus  anticus,  and  below  by  the  first  ril) ; 
place  the  patient  on  his  back,  the  shoulders  depressed,  and  the  head 
turned  to  tlie  opposite  side  ;  the  skin  over  the  parts  being  drawn  down 
upon  the  clavicle,  make  an  incision  along  the  bone  from  the  anterior 
bonier  of  tlic  trajK'zius  to  the  posterior  border  of  the  sterno-mastoid; 
divide  the  platysina  and  superficial  fascia,  care  being  taken  to  draw  tiie 
external  jugular  outward,  or,  if  cut,  to  tie  tiic  ends;  with  the  director 
and  finger  separate  the  celkdar  and  fatty  tissue,  and  draw  the  omo-hyoid 
muscle  aside  ;  divide  the  deep  fascia,  and,  the  border  of  the  scalenus 
being  defined,  pass  the  finger  along  its  margin  down  to  the  first  rib ; 
recognize  the  tubercle  for  the  attaclinient  of  tiiat  muscle,  just  external  to 
which  tile  artery  will  be  felt  pulsating  ;  se])arate  the  attaclimeuts  of  the 
artery  witli  the  finger-nail,  and  gently  insinuate  the  aneurism  needle 
l)crieath  it,  from  before  backward,  and  slightly  from  M'ithin  outward, 
avoiding  the  vein ;  guide  the  jioint  of  the  needle  by  the  end  of  tlie 
finger,  and  prevent  it,  when  it  emerges  upon  the  opposite  side,  from 
engaging  a  branch  of  the  bracliial  ph'xus.  It  must  be  remembered  that 
the  sterno-mastoid  may  have  an  unusually  extended  insertion  upon  the 
clavicle,  as  also  the  trapezius,  in  wiiich  case  the  incision  must  involve 
the  clavicular  attachments  of  the  former  ;  the  external  jugular,  supra- 
scapular, and  transverse  cervical  veins  form  ;i  jilexus  immediately  over 


756 


OPERATIVE  SURGERY. 


the  artery ;  the  external  jiif;iilar  may  I'un  so  near  to  the  sterno-mastoid 
as  to  be  involved  in  tlie  incision,  unless  it  is  carefully  isolated  and  drawn 
to  the  outer  or  inner  side ;  the  transverse  cervieal  and  supra-sca])idar 
arteries  may  he  met  \yith  in  this  dissection,  and  if  wounded  shoidd  be 
iiniiiediately  ligatcd ;  tlie  tubercle  of  the  rib  is  sometimes  not  well 
defined,  in  which  case  the  tense  cdfi'c  and  attachment  of  the  scalenus 
to  tlie  rib  are  the  guides  to  the  artery,  which  is  found  just  posterior  to  its 
insertion  ;  there  is  a  liability  to  include  the  lowest  cord  of  the  brachial 
plexus,  or  even  to  mistake  it  for  the  artery;  the  former  is  round  and 
tense,  the  latter  is  flattened. 

The  aj-illari/  (irfcri/  extends  from  the  lower  border  of  tlie  first  rib  to 
the  lower  margin  of  the  tendon  of  the  latissimus  dorsi  or  the  inferior 
boundary  of  the  axilla,  in  a  line  dividing  the  anterior  and  middle  third 
of  the  axilla.  It  may  be  ligatcd  in  two  places,  (a)  Below  the  clavicle, 
in  its  upper  part,  the  axillary  artery  is  covered  successively  by  the 
insertion  of  the  pectoralis  minor ;  higher  up  by  the  pectoralis  major 
muscle,  from  which  it  is  separated  l>y  a  layer  of  adipose  tissue  contain- 
ino-  numerous  small  veins  and  arteries;  and  finally  liy  tlie  fasciae  and 
the  skin  (Fig.  237).  The  supra-scapular  artery  crosses  the  base  of  the 
neck  just  above  the  clavicle ;  the  axillary  vein,  in  front  and  to  the 
inner  side  of  the  artery,  is  not  in  immediate  contact  with  it ;  the  cephalic 
vein  passes  upward  in  the  interspace  between  the  deltoid  and  jieetoralis 
major  muscles,  crosses  the  axillary  artery  above  the  jiectoralis  minor, 
and  empties  into  the  axillary  vein ;  the  nerves  of  the  brachial  plexus  lie 
behind  and  above  ;  a  thoracic  branch  often  crosses  the  artery,  sometimes 
in  front  antl  sometimes  behintl  it.     Place  the  patient  on  his  back  M'ith 

his  shoulders  slightly  raised,  the 
elbow  a  little  separated  from  the 
body,  and  the  head  inclined  to 
the  opposite  side ;  make  an  in- 
cision, three  inches  in  length, 
thrcc-(juarters  of  an  inch  below 
the  clavicle,  and  commencing 
about  two  inches  outside  of  the 
sterno-cla vicular  articulation, 
through  the  skin,  platysma,  and 
subcutaneous  cellular  tissue  ;  sep- 
arate the  fibres  of  the  pectoralis 
major  gradually  until  the  posterior 
investment  of  this  muscle,  like  an 
aponeurosis,  appears  ;  now  depress 
the  shoulder  and  tear  this  fascia 
with  the  point  of  the  director ;  press  downward  and  out-\vard  w  ith  the 
finger  the  upper  border  of  the  pectoralis  minor,  when  the  axillary  vein 
is  lirought  to  view ;  draw  this  gently  forward  with  a  blunt  hook,  and 
behind  it  the  artery  is  found,  with  the  nerves  of  the  brachial  plexus 
still  farther  behind  and  above  ;  pass  the  needle  from  within  outward. 
(6)  Below  the  ]icctoralis  minor,  in  its  lower  third,  the  artery  is  super- 
ficial, covered  only  l>y  the  integuments  and  deep  fascia.  The  coraco- 
braehialis  muscle  is  in  contact  A\'ith  the  artery,  and  may  be  found  at  its 
internal  and  posterior  border ;  the  bj-anches  of  the  brachial  plexus  of 


p. in 


The  first  part  of  the  right  axillary  artery :  p.  m.  a, 
peetoralis  major,  thti  fibres  separated  in  llie 
inner  half  of  the  wouud  and  divided  in  the 
outer;  p.vi.i,  pectoralis  minor;  a.  t,  aeromio- 
thoracic  artery  and  vein ;  v,  axillary  vein ;  a, 
axillary  artery ;  n,  brachial  plexus. 


LIGATURE  OF  ARTERIES. 


757 


nerves  surround  the  artery  ;  tlic  niusculo-cutancous  lies  along  the  outer 
side ;  the  two  roots  of  the  median  meet  in  front  at  the  loMer  border  of 
tlie  pectoralis  minor ;  the  nerve  then  lies  in  front  and  to  the  outer  side 
of  the  artery  ;  the  internal  cutaneous  lies  in  front  and  to  its  inner  side ; 
the  ulnar  and  radial  are  still  farther  within  and  Ijehind  ;  the  axillary 
vein  is  in  front  of  the  arter}-  and  nerves,  which  it  partly  conceals  (Fig. 
238).  Place  the  patient  on  the  back,  the  arm  rotated  outward ;  stand 
on  the  outside  if  it  is  the  right  arm,  and  on  the  inner  side  if  it  is  the 
left ;  recognizing  the  inner  border  of  the  coraco-brachialis  muscle  and  the 

Fig.  -IZ^. 
Caraco-brachlatis  viuscle. 


%S!- 


Jvt.  ciUaneoas  nerve. 


Ligature  of  axillary  artery,  upper  third. 


})ulsations,  make  an  incision  two  or  tJn-ee  inches  in  length  in  the  line 
indicated,  dividing  only  the  skin;  incise  the  fascia  on  a  director;  with 
the  end  of  the  director  ])ush  the  axillary  vein  backward,  then  the  bra- 
chial ])lexus ;  the  median  nerve  is  now  recognized,  and,  being  brought 
forward,  while  tiie  internal  cutaneous  and  ulnar  are  pushed  backward, 
the  artery  is  exposed  ;  separate  the  artery  carefully  from  the  vein,  which 
is  pushed  backward,  and  tiie  nerves  which  surround  it,  and  pass  the 
needle  from  behind  forward. 

The  bmchial  artery  extends  from  the  lower  margin  of  the  axilla  to 
an  inch  below  the  bend  of  the  elbow,  in  a  line  drawn  from  the  junction 
of  the  anterior  with  the  middle  third  of  the  axilla  to  the  middle  of  the 
bend  of  the  elbow. 

(ff)  In  the  upper  third,  the  arm  being  extended  as  before,  make  an 
incision  two  and  a  half  inches  in  length  along  the  inner  border  of  the 
coraco-brachialis ;  the  artery  is  readily  exposed,  lying  between  and 
behind  the  median  and  ulnar  nerves,  the  former  to  the  outside  and  the 
latter  to  the  inside. 

(6)  Tn  the  middle  of  die  arm  the  l)rachial  descends  on  tlie  inner  side, 
first  of  the  coraco-brachialis,  and  afterward  of  the  liice]is.  It  is  covered 
by  the  fascia  and  integuments,  and  overlap])cd  slightly  by  the  biceps ; 
its  sheath  contains  the  two  vente  comites  ;  the  internal  cutaneous  nerve 
lies  superficial  to  it ;  the  median  is  superficial  to  it  above,  and  rather  to 
its  outer  side ;  about  the  middle  of  the  arm  it  crosses    the  artery,  and 


ros 


OPERATIVE  SURGERY. 


iiifcriorly  it  is  to  its  ulnar  side  ;  the  ulnar  nerve  is  internal  to  the  artery, 
and  at  some  distance  from  it  interiorly;  the  spiral  nerve  is  posterior,  and 
.separates  it  above  from  the  trieej)s  (Fifj.  239).  The  arm  extended  at 
i'i};iit  angles  to  the  hody  and  held  sujiine,  the  course  of  the  artery  may 
he  recognized  by  its  pulsation ;  by  the  internal  margin  of  the  biceps  and 


Fio.  239. 


Biceps  muscle. 


Median  nerve. 
Brachial  artery  iu  the  middle  of  the  arm. 


coraco-brachialis  ;  by  the  median  nerve,  to  the  inner  side  of  wliich  it 
lies ;  or  by  the  line  above  given.  Make  an  incision  two  or  three  inches 
in  length  along  the  inner  border  of  the  biceps  down  to  the  fascia,  which 
incise  on  a  director  ;  tlie  ])ositioii  of  the  median  nerve  is  detected  in  the 
wound  ;  push  it  aside  with  the  bice|)s  ;  the  artery  is  found  immediately 
beiiind  and  inside,  accompanied  by  its  vcnse  comites.  The  arm  is  now 
flexed,  the  vessel  isolated,  and  the  ligature  passed  from  witliout  inward. 
If  the  incision  is  made  a  little  too  far  back,  the  ulnar  nerve  is  exposed, 
and  is  liable  to  be  mistaken  for  the  median  ;  and  this  error  may  be  con- 
firmed by  the  presence  of  the  vein,  occupying  the  same  relative  position 


Fig.  240. 

Tendinous  aponeurosis 
divided. 


.->> 


Brachial  arterj  at  tile  elbow. 


as  the  brachial  to  the  median,  which  may  be  mi.staken  for  the  artery,  and 
then  the  inferior  jirofunda  will  be  tied  for  the  brachial. 

(c)  At  the  elbow  the  brachial  artery  lies  in  the  centre  of  a  triangular 
sjiace  formed  by  the  supinator  longus  externally  and  the  pronator  radii 
teres  internally.     It  rests  on  the  brachialis  anticus ;  the  median  nerve 


LIGATURE  OF  ARTERIES. 


759 


lies  to  the  inner  side  half  an  inch  ;  the  tendon  of  the  Ijiceps  lies  on  the 
outer  side  ;  its  coverings  are  the  skin,  superficial  fascia,  and  the  median 
basilic  vein,  which  is  separated  by  the  bicii)ital  fascia. 

The  arm  extended  and  hehl  in  a  supine  position  (Fig.  240),  malve  an 
obliijue  incision,  two  inches  and  a  half  in  length,  along  the  internal  edge 
of  tile  tendon  of  tile  biceps,  within  tiic  median  basilic  vein,  dividing  imly 
tiie  skin  ;  push  aside  the  vein  and  divide  tiie  aixinenrosis,  which  is  tlie 
deep  fascia,  on  a  director;  the  tendon  of  the  biceps  is  now  seen,  and  on 
its  inside  the  artery  with  its  two  veins,  and  still  farther  inward  the 
median  nerve  ;  slightly  flex  the  forearm,  and  pass  the  needle  from  within 
outward,  carefully  avoiding  the  veins. 

Tlie  mdial  artery,  though  the  smaller  brancli  of  the  brachial,  lies  in 
the  direct  course  of  the  latter  like  a  continuation  ;  its  course  is  marked 
by  a  line  drawn  from  tlie  centre  of  the  elbow  to  the  inner  side  of  the 
styloid  process  of  the  radius;  is  superficial  tliroughout  nearly  its  entire 
course  ;  the  needle  may  be  passed  in  either  diri'ction.  (a)  In  its  upper 
third  the  artery  lies  between  the  supinator  longus  and  the  pronator  radii 
teres;  the  radial  nerve  lies  immediately  on  its  external  side  (Fig.  241). 

Fio.  241. 

Supinator  tongus. 


Ligature  of  radial  artery  in  its  iijii)CT  third. 


The  limb  being  extended  supine,  tiie  superficial  veins  made  prominent 
by  pressure  of  the  thumb  above,  make  an  incision  two  or  three  inches  in 
length  on  the  internal  border  of  the  su]iinator  longus,  if  recognized  by 
the  depressidu,  or  on  a  line  drawn  from  the  middle  of  the  bend  of  the 
elbow  to  the  inner  side  of  tiie  styloid  ])r(icess  of  the  radius,  dividing  tlie 
skin  and  sin)erficial  fascia  ;  divide  the  deep  fascia  on  a  director;  flex  the 
arm  slightly  to  relax  the  muscles;  the  supinator  longus  being  drawn 
aside,  the  sheath  of  the  artery  is  exposed  ;  pass  the  needle  from  Mithout 
inward. 

(h)  In  its  lower  third  the  artery  is  sujierficial,  lying  between  the 
tendons  of  the  supinator  longus  and  the  flexor  carpi  radialis  ;  it  is  accom- 
panied by  vena^  eomitcs  and  by  tlie  radial  nerve,  wiiich  lies  external ; 
its  |)ulsati(m  is  easily  detected  (Fig.  244).  The  arm  held  su])ine,  the 
hand  forcibly  extended  to  make  prominent  the  flexors,  and  the  operator 
standing  on  the  external  side  of  the  limb,  make  a  light  incision  two 
inches  in  length,  from  half  an  inch  above  the  articulation  of  the  radius, 
on  the  external  border  of  the  flexor  caqii  radialis,  or  on  a  line  joining 
the  external  with  the  three  internal  fourths  of  the  arm;  the  dee])  fascia 
is  raised  on  a  director,  exposing  the  artery  with   its  two  veins,  and  the 


760 


OPEEATIVE  srnOERY. 


l'(IR'  IIKIV   !)(' 


pa; 


sed  in  citlier  dir 


rcc- 


Radial  artery  at  the  wrist. 


nerve,  external  and  posterior ;  tlie  nci'( 
tiou. 

((•)  On   the  dorsum  of  tlie  wrist  (Kig.  24'2)  the  artery  passes  in  the 

groove  between  the  up])er  extremi- 
ties of  the  first  metacarpal  bones ; 
a  fibrous  band  separates  it  fi-om 
the  tendons  of  the  thunil).  It  may 
be  tied  just  as  it  is  about  to  form 
the  palmar  arch,  or  as  it  passes 
under  the  extensor  muscle  of  the 
tliumlj,  between  the  extensor  primi 
internodii  and  tlie  extensor  secundi 
internodii  pollicis,  a  little  below 
and  posterior  to  the  extremity  of 
the  styloid  process  of  the  radius. 
Make  an  incision  an  inch  in  length 
along;  the  outer  borders  of  the  ex- 
tensor  secundi  and  metacarjii  pollicis,  at  the  angles  formed  by  the  two 
first  metacarpal  bones,  care  being  taken  not  to  wound  the  sujierfieial 
veins  ;  the  artery  is  readily  cxjiosed.  At  the  higher  jioint  ])lace  the  hand 
between  pronation  and  supination,  the  thumb  strongly  abducted  so  as  to 
render  prominent  the  extensors,  and  make  an  incision  an  inch  in  length 
between  the  tendons  of  the  two  extensors,  commencing  at  the  lower 
extremity  of  the  radius  and  in  the  line  of  the  axis  of  the  first  metacarpal 
bone  ;  makes  these  incisions  lightly,  to  avoid  the  superficial  vein  of  the 
thunil);  draw  the  extensor  ossis  metacarpi  pollicis,  a,  inward,  and  the 
extensor  secundi  internodii  pollicis,  d,  outward ;  expose  the  artery,  c, 
and  its  accompanying  veins,  b. 

The  ulnar  arfcri/  is  indicated  by  a  line  drawn  from  the  internal  tuber- 
osity of  the  OS  brachii  to  the  external  side  of  the  pisifiirni  bone,  (a)  In 
its  upper  third  the  ulnar  artery  curves  inward  deeply  liencath  the  fiexor 
muscles,  and  passes  along  the  ulnar  side  of  the  forearm,  between  and 
covered  by  the  ilexor  carpi  ulnaris  and  flexor  sublimis  digitorum  ;  it  is 
accompanied  by  two  veins  and  by  the  ulnar  nerve,  which  is  more  super- 
ficial and   internal  (Fig.  24.3).     The   forearm  being  supine,  the  hand 

extended  and  inclined  to  the  radial  side,  make 
an  incision  on  the  imaginary  line  given,  three 
inches  in  length  and  l)egiiining  three  fingers' 
breadth  below  the  internal  condyle  through 
the  skin  and  superficial  fascia,  and  recognize 
the  aponeurotic  connection  of  the  flexor  carpi 
ulnaris  and  flexor  sublimis,  which  is  of  a 
yellov>ish-wliite  color  ;  divide  it  on  the  direc- 
tor from  lielow,  where  it  is  the  most  delicate, 
carefully  avoiding  the  division  of  muscular 
substance ;  the  flexor  sublimis,  a,  is  drawn 
outward,  and  the  deep  aponeui-osis  exposed, 
under  which  lies  the  artery  ;  if  the  vessel  is 
not  seen,  press  the  flexor  carpi  ulnaris,  e,  inward,  and  expose  the  ulnar 
nerve,  b,  a  little  external  to  which  lies  the  arter}-,  e,  ^^•ltll  its  two  veins, 


Fig.  243. 


abed     e 
The  ulnar  artery  in  its  upper  third. 


LIGATURE  OF  ARTERIES. 


761 


d ;  isolate  the  artery  by  Hexing-  the  arm  slightly  and  the  hand  strongly  ; 
pass  the  needle  from  \vithoat  outward. 

(6)  In  its  lower  third  the  artery  is  superficial,  iiaving  upon  its  inner 
side  the  flexor  carpi  ulnaris  and  ulnar  nerve,  and  upon  its  external  side 
the  flexor  sublimis  digitorum.  Place  the  arm  supine  and  extend  the 
liand  so  as  to  make  prominent  the  tendon  of  the  flexor  carpi  ulnaris ; 
then  along  the  radial  border  of  this  nniscle  (Fig.  244),  or  at  the  union 

Fig.  244. 


Fig.  245. 


Ligature  of  the  radial  and  iilnar  arteries  at  the  lower  third. 

of  the  external  four-fifths  of  the  arm  with  tlie  internal  fifth,  or  on  a  line 
drawn  from  the  internal  condyle  to  the  pisiform  bone,  make  an  incision 
about  two  inclies  in  lengtii  through  the  skin  and  subcutaneous  cellular 
tissue  ;  raise  the  deej)  fascia  on  a  director  or  with  the  forceps,  and  incise 
it,  exposing  the  tendon  of  the  flexor  carpi 
nhiaris  ;  this  should  be  pressed  inward,  and 
immediately  behind  it  the  artery  will  be 
found  with  its  two  accompanying  veins,  and 
the  nerve  upon  the  inside. 

{(■)  At  the  wrist  (Fig.  245)  the  artery  lies 
to  the  radial  side  of  the  pisiform  bone,  and 
is  accompanied  by  its  veins,  b,  and  the  ulnar 
nerve,  c,  which  lies  on  its  internal  and  ])os- 
terior  aspect.  The  hand  being  held  back, 
make  a  slightly  curved  incision  on  the  radial 
side  of  the  pisifijrm  l^one,  through  tlie  skin 
and  adipose  tissue,  about  three  inches  in 
length,  its  concavity  looking  inward  ;  the 
artery,  o,  is  dee})ly  seated  in  a  groove,  and  the  dissection  should  be  con- 
tinued along  the  side  of  tlie  pisiform  bone  until  it  is  exposed :  the  latter 
part  of  the  dissection  will  be  facilitated  by  flexing  the  hand  upon  the 
forearm  ;  pass  tiie  needle  beneath   from  within  outward. 

The  SHpcj-firial  palmar  arch  is  tiic  continuation  of  tiie  ulnar  artery 
into  the  hand  (Fig.  24(j).  Near  the  lower  border  of  the  annular  liga- 
ment tills  artery  turns  oblicpiely  outward  across  the  palm  of  the  hand 
toward  tiie  middle  of  tiie  muscles  of  the  thumb,  where  it  inosculates  with 
a  small  branch  of  the  radial,  the  superficialis  volse.  At  its  commence- 
ment it  rests  on  the  annular  ligament  of  the  wrist  and  slightly  on  the 
siiort  muscles  of  the  little  finger,  then  on  the  tendons  of  the  superficial 
flexor  of  tlie  fingers  aii<l  the  divisions  of  tlie  median  and  ulnar  nerves, 
tlie  latter  nerve  acconii>aiiyiiig  the  vessel  for  a  short  distance  ;  it  is  cov- 


a  h  c 
Ulnar  artery  at  the  wrist. 


702 


OPERATIVE  SURGERY. 


ci'cd  townnl  the  ulnar  hordcr  i)f  tliu  hand  hy  tlic  palmaris  brcvis  and  the 
[lahnar  tiiscia  and  intcgnmcnt.  The  central  purtiun  of  a  transvei'se  line 
ilrawn  across  the  palm,  from  the  angle  of  the  web  between  the  thumb 


Fig.  247. 


Fic).  246. 


Position  and  mode  of  formation  of  the 
palmar  arches  and  distribution  of 
the  digital  arteries. 


Lines  of  incision  :  .4,  line  indicating  convexity  of 
arch ;  A',  line  of  incision  for  arch :  B,  line  indi- 
cating the  cubital  branch  of  the  arch ;  B',  line 
of  incision  for  this  branch ;  PI,  inferior  palmar 
fold  (Chalot). 


and  index  finger,  corresponds  pretty  accurately  with  the  position  of  the 
middle  of  the  superficial  palmar  arch  ;  if  tlie  tliumb  be  abducted,  its 
anterior  surface  is  continuous  in  direction  with  the  ])almar  outline  of  the 
ball  of  the  thumb,  which  will  then  become  parallel  to  the  middle  palmar 
fold  ;  the  vessel  lies  jjarallel  to  and  equidistant  between  them  (^NlacCor- 
mac).  Make  an  incision  one  inch  long  midway  between  and  parallel  to 
these  lines,  and  nearly  opposite  to  the  bases  of  the  middle  and  ring 
fingers ;  divide  the  skin  and  palmar  fascia,  and  the  arch  will  be  brought 
to  view  at  the  thicker  part  of  the  ulnar  artery  (Fig.  247). 


ARTERIES   OF   THE   LOWER    EXTREMITY. 

The  abdominal  aorta  lies  in  front  and  a  little  to  the  left  side  of  the 
bodies  of  the  vertebme,  having  the  vena  cava  on  its  right  side,  the  sym- 
pathetic nerve  on  its  left,  and  the  left  lumbar  veins  behind  ;  it  divides 
on  the  lower  part  of  the  fourth  lumbar  vertebra  at  a  j)oint  nearly  corre- 
sponding to  the  uml)ilicus  ;  it  may  be  ligated  about  one  inch  above  its 
bifurcation,  between  it  and  the  origin  of  the  mesenteric.  It  can  be  ex- 
posed and  successfully  ligated  by  the  operation  for  the  common  iliac  : 
the  artery  being  separated  from  the  vein,  with  the  finger  or  a  director 
pass  the  needle  from  right  to  left.  Or  make  an  incision  along  the  linea 
alba  three  inches  in  length,  the  middle  of  it  on  a  level  with  the  umbil- 
icus, but  a  little  to  the  left  ;  open  the  peritoneum  ;  push  the  intestines 
aside  ;  detect  the  artery  by  its  pulsations ;  separate  the  ])critoneal  cover- 
ing with  the  finger-nail  on  the  left  side,  carry  the  finger  under  the  vessel 


LIGATURE  OF  ARTERIES. 


763 


and  pass  the  needle  ;  or  make  an  incision  from  the  extremity  of  the  tenth 
ril)  downward  six  inches,  curving  Ijackward  to  Mithin  an  inch  of  the 
anterior  spine  of  the  ilium,  Q  (Fig.  24S),  and  reach  the  aorta  from  the 
side  bv  raising  the  peritoneum.  All  the  antiseptic  precautions  of  peri- 
toneal section  must  be  enforced. 

The  common   iliac,  artery  (Fig.  248)  varies  from  three-quarters  of  an 

Fig.  2-18. 


The  common  iliac. 


inch  to  three  inches  in  length,  averaging  about  two ;  it  passes  from  the 
bifurcation  of  the  abdominal  aorta  on  the  left  side  of  the  body  of  the 
fiurth  lumbar  vertebra,  a  point  corresponding  with  the  left  side  of  the 
nnil)ilieus,  on  a  level  with  a  line  drawn  from  one  crista  ilii  to  the  other, 
<l(iwnward  and  outward  along  the  margin  of  the  pelvis  to  the  sacro-iliac 
svnchondrosis ;  the  artery  upon  the  right  side  is  on  an  average  the  same 
length  as  that  upon  the  left,  and  has  in  front  the  peritoneum  and  at  its 
point  of  division  the  ureter.  The  following  method  of  operating  is  now 
to  be  preferred  :  Provide  large  flat  aseptic  sponges,  small  sjjonges  with 
sjionge-liolders,  hot  sublimate  solutions  for  douche,  spatulte,  and  an  aneu- 
rism needle  armed  with  a  carbolized  silk  or  catgut  lig-ature  ;  cleanse  the 
surtace  of  the  abdomen  and  empty  the  bladder.  Make  an  incision  in 
the  median  line  four  inches  in  length,  commencing  at  the  symphysis, 
through  the  superficial  tissues  down  to  the  linca  alba ;  ligate  all  bleeding 
vessels  ;  open  this  aponeurosis  at  the  upjier  end  of  the  incision  cautiously 
bv  raising  a  fold  with  forceps  and  cutting  witli  the  point  of  the  knife  ; 
divide  it  throughout  on  the  director;  in  the  same  manner  incise  the 
transversalis  fascia,  thus  exposing  the  ]ieritoneum  ;  raise  a  fold  of  the 
peritoneum  with  foreejjs  and  open  it  with  the  point  of  the  knife,  and 
then  enlarge  the  opening  on  the  fingers.  Now,  with  tlie  flat  sponges 
wrung  out  of  liot  bichloride  solution,  push  the  intestines  gently  upward 
until  tlic  region  of  the  artery  is  fidly  ex])osed  ;  if  the  intestines  are  so 
distended  that  they  cannot  be  pushed  U])ward  out  of  the  way,  draw  them 
gently  out  of  the  wound  upon  the  abdomen,  first  covered  with  towels 
wrung  out  of  the  hot  sublimate  solution,  and  keep  them  covered  with 
the  hot  sponges.  Drawing  the  side  of  the  wound  toward  the  artery 
with  a  spatula,  the  vessel  will  be  fully  exposed;  avoiding  the  ureter, 
pick  up  the  sheath  of  the  artery  with  forceps;  open  it  with  the  point  of 


764 


OPERATIVE  SUIiGERY. 


tlif  knife  on  the  inner  aspcrt  and  niifover  the  vessel ;  pass  tlic  needle 
fVoin  within  ontward.  After  ligating  the  artery  ent  the  ends  of  the  liga- 
ture ;  with  tlie  small  sponges  remove  tlie  idood,  if  tliei'e  is  any,  from  the 
eavity ;  return  the  bowels  gently  with  as  little  manipulation  as  possible. 

If  the  operation  be  performed  without  opening  the  peritoneum,  pur- 
sue the  following  method  :  The  i)atient  being  ])laced  on  the  itack  (Fig. 
'248),  inclining  to  the  opposite  side,  make  an  incision,  n,  eonuuencing  just 
anterior  to  the  t'xtremity  of  the  eleventh  I'ib  downward,  one  and  a  half 
inelus  within  tile  anterior  su})erior  spine,  and  terminating  just  al»ove  the 
internal  ring  liy  a  sharp  curve  upward  and  inward  of  an  inch  ;  the  entire 
length  is  about  seven  inches ;  divide  the  integuments  and  superticial 
fascia  ;  then  the  three  abdominal  muscles ;  cautiously  raise  the  fiiscia 
transversalis  from  the  peritoneum,  first  at  the  u])per  part  of  the  wound 
where  the  union  is  slightest;  now  gently  elevate  tlie  peritoneum  and 
press  it  inward  from  the  iliac  fossa  toward  the  pelvis;  the  ])nlsations  of 
the  external  iliac,  f,  arc  first  recognized,  and  the  finger  carried  upward 
along  this  vessel  reaches  the  common  trunk  ;  the  ureter,  H,  in  front  is 
carefully  pushed  aside,  and  the  needle  jiassed  from  within   outward. 

The  interndl  iliac  (trfer//,  e  (Fig.  248),  is  an  inch  and  a  half  in  length, 
extending  from  the  bifurcation  of  the  common  iliac  downward  and  for- 
ward to  the  upper  margin  of  the  great  sacro-seiatie  foramen  ;  it  is  in 
relation  anteriorly  with  the  ureter,  ii,  which  se])arates  it  from  the  perito- 
neum ;  posteriorly  with  the  internal  iliac  vein  ;  it  rests  on  the  sacral 

Fig.  249. 


Position  nnd  direction  of  tlie  superficial  incisions  which  must  be  made  to  secure  the  gluteal  artery 
and  the  sciatic  or  pudie  arteries:  A,  posterior  superior  iliac  spine:  B,  great  trochanter;  C\ 
tuberosity  of  the  ischium;  />,  anterior  superior  iliac  spine. 

Aj  B,  ilio-trochanterlc  line,  divided  into  thirds.  This  line  corresponds  in  direction  with  the  fibres 
of  the  gluteus  niaximus  muscle.  The  incision  to  reach  the  gluteal  artery  is  indicated  by 
the  darker  j.urtii.n  of  the  line.  Its  centre  is  at  the  junction  (it  the  ui'iier  withtlie  middle  third 
of  the  iliO'trochanteric  line,  and  exactly  corresponds  with  the  point  of  emergence  of  the 
gluteal  artery  from  the  great  sciatic  notch. 

-1,  (\  iiio-ischiatic  line.  The  incisitm  to  reach  the  sciatic  artery,  or  internal  pudic,  is  indicated  by 
the  hiwer  dark  line.  It  is  also  tn  be  made  in  the  direction  of  the  fibres  of  the  gluteus  maximus 
muscle.  The  centre  of  the  wound  corresponds  to  the  junction  of  the  lower  with  the  middle 
third  of  the  ilio-ischiatic  line. 


plexus  of  nerves  and  the  pyriformis  muscle ;  on  the  left  the  rectum  lies 
])artially  over  it.  The  artery  may  be  exjiosed  and  ligatcd  by  the  methods 
described  in  the  operation  on  the  primitive  iliac. 

The  gluteal  artery  emerges  from  the  ])clvis  at  the  upper  part  of  the 


LIGATURE  OF  ARTERIES. 


765 


Fig.  250. 


Ligature  of  gluteal  artery. 


great  i.'^c-hiatic  notch,  above  tlie  ui)per  border  of  the  pyriformis  mu.scle.s. 
A  line  drawn  from  the  posterior  superior  spine  of  the  ilium  to  the  top 
of  the  great  troehanter  marks  the  course  of  the  artery  (Fig.  249).  In 
the  oi>eration  (Fig.  250)  place  the  patient  in  a  prone  position ;  make  an 
incisiiin  on  the  line  above  indicated  four  or  iive  inches  long,  terminating 
about  an  inch  and  a  half  from  the  spine  ;  the  cut  is 
parallel  with  the  fii)res  of  the  gluteus  maximus, 
which  should  be  separated,  and  the  finger  intnxlueed 
to  detect  the  pulsations  of  the  artery  ;  separate  the 
pvriformis  and  gluteus  medius  muscles,  the  borders 
of  ^v•hich  cover  the  vessel,  and  isolate  the  artery 
from  its  veins,  and  pass  the  needle  as  deeply  as 
possible,  as  the  artery  divides  just  after  its  emerg- 
ence. 

The  sciatic  artery  escapes  from  the  pelvis  between 
the  jivriformis  and  coccygeus  muscles,  and  descends 
in  tiie  interval  between  tiie  trochanter  major  and 
tuberosity  of  the  iscliium.  It  is  covered  by  the 
gluteus  ma.Kimus,  and  is  accompanied  by  the  sciatic 
nerve  and  the  vein  which  lies  to  its  posterior  and 
inner  side  ;  the  centre  of  a  line  drawn  from  the 
posterior  superior  spinous  process  of  the  ilium  to 
the  tuberosity  of  the  ischium  marks  the  point  of  exit  of  the  artery  from 
the  pelvic  cavity.  The  patient  being  jirone,  make  an  incision  four 
inches  in  length,  the  centre  of  wliich  falls  upon  the  jioint  of  emergence 
of  the  artery,  as  given  above  (Fig.  249)  ;  divide  the  skin,  cellular  tissue, 
and  the  fibres  of  the  gluteus  maximus  ;  the  artery  is  found  to  the  inside 
of  the  nerve,  and  must  be  carefully  isolated  from  the  vein. 

The  internal  pudic  artery,  the  smaller  of  the  two  terminal  branches 
of  the  internal  iliac,  ])asses  out  of  the  pelvis  through  the  great  sacro- 
.sciatie  foramen,  internal  to  the  sciatic  artery  ;  it  again  enters  the  pelvis 
through  the  lesser  sacro-sciatic  foramen,  runs 
along  the  I'amus  of  the  ischium  and  pubis, 
and  divides  into  the  arteries  of  the  penis. 

{a)  At  the  greater  saero-sciatie  foramen 
make  the  same  iucisi(jn  as  in  the  ligature  of 
the  sciatic  artery  ;  the  pubic  is  found  a  little 
internal,  accompanied  by  its  veins  and  the 
pudic  nerve. 

(Ij)  In  the  perineum  (Fig.  251)  the  artery 
may  be  ligated  as  it  descends  the  ramus  of 
the  ischium  ;  draw  a  line  from  the  middle 
of  the  puljcs  to  the  internal  Ijorder  of  the 
tuber  ischii.  The  pirtient  being  placed  in 
the  position  for  lithotomy,  make  an  in- 
cision two  inches  in  length  along  the  ramus 
of  the  pubis,  near  the  arch  ;  the  vessel  is 

found  along  the  inner  border  of  the  ramus,  Ligature  of  hii.mni  i.u.iio  artery. 
where   it  may  be  isolated  and   the  ligature 
applied;  care  .should  be  taken   not   to  incise  the  corpus  cavernosum. 

The  external  iliac  artery  (Fig.  252),  fmr  inches  in  length,  passes  ob- 


FiG.  2.51. 


766  OPEnATIVE  SURGERY. 

licjiK'lv  (lowmvard  niid  out  WMrd  IVoni  the  saoro-iliac  symphysis  to  Pou]iai't's 
litiaiiicnt,  in  a  lint'  drawn  from  the  left  side  of  the  umbilicus  to  a  point 
midway  between  the  anterior  supt^rior  spine  of  the  ilium  and  the  symphysis 
pubis.  In  its  u]iper  jiortion  it  has  in  front  the  peritoneum  and  intestines, 
and  near  Pou])art's  liiiaiiient  the  s])ermatic  vessels,  genito-erural  nerve,  cir- 
cumflex iliac  vein,  lyinpliatie  vessels  and  li'lands  ;  externally,  tlic  jisoas  mau- 
nus,  from  wliich  it  is  separated  by  the:  iliac  fascia  ;  internally,  the  external 
iliac  vein  ;  below  and  curving;;  along  its  side,  the  vas  deferens  ;  behind,  it 
rests  above  upon  the  external  iliae  vein,  which  gradually  ])asses  to  its 
internal  side.  Place  the  jjatient  in  a  recumbent  position,  the  muscles 
relaxed  by  elevation  of  the  jx'lvis;  make  an  incision  three  or  four 
inches  in  length,  commencing  about  an  inch  and  a  half  within  the 
anterior  superior  spine  of  tlie  ilium  and  on  a  level  with  tliis  ])rocess,  and 
extending  in  a  curved  direction  downward  and  inward  nearly  ])arallel 
with  Poupart's  ligament,  and  terminating  an  inch  and  a  half  above  it, 
just  outside  of  the  external  abdominal  I'ing.  On  the  left  side  it  will  be 
found  convenient  to  eonnnencc  tiie  incision  internally,  at  the  externa! 
ring  and  carrv  it  upward  and  outward  to  the  point  indicated  within 
the  anterior  superior  sjiine.  Incise  the  integuments  and  fascia,  care- 
iully  av(_)iding  the  superficial  epigastric  artery ;  the  aponeurosis  of  the 

Fig.  252. 


Ligature  of  right  external  iliac  artery  (mndiUccl  Cooper's  method) :  A,  aponeurosis  of  externaloblique: 
B,  conjoined  tendon ;  C,  internal' oblique ;  D,  transversalis  fascia;  £,  peritoneum ;  a,  est.  iliac 
artery ;  b,  est.  iliac  vein ;  c,  deep  epigastric  artery  (Treves). 

external  oblique  muscle  is  now  exposed  and  divided  on  a  director ;  in 
the  same  manner  divide  the  tibres  of  the  internal  oblique  and  tran.s- 
versalis  muscles  until  the  transversalis  fascia,  recognized  by  its  white 
opaque  ap})earancc,  is  exposed  ;  cautiously  open  this  membrane  and 
incise  on  the  director;  the  peritoneum  is  now  exposed  and  carefully 
detached  from  the  iliac  fossa,  and  pushed  toward  the  pelvis ;  the  artery 
is  readily  felt  pulsating  at  the  bottom  of  the  wound,  along  the  inner 
border  of  the  psoas  muscks  the  vein  being  on  the  inner  aspect,  the 
o-cnito-crural  nerve  external  ;  open  the  sheath  and  insinuate  the  needle 
from  within  outward   to  avoid  the  vein.     Or  the  finger  may  be  passed 


LIGATURE  OF  ARTERIES. 


mi 


Fig.  253. 


into  tlio  internal  ring  along-  the  sperniatie  eord  and  the  iliac  fascia  rai.sed 
in  tills  manner.  Other  incisions  are  made  in  the  course  of  tjie  artery 
(Fig.  248,  a),  tliree  inches  in  lengtli  ;  a  curved  incision  (Fig.  '248,  c), 
commencing  a  little  above  the  spine  of  tiie  ileum,  and  terminating  a 
little  above  the  internal  edge  of  the  inguinal  ring  ;  an  incision  (Fig. 
248,  b)  in  the  centre  of  the  space  between  the  interior  spine  and  the 
symphysis  pubis. 

'V\w  femoral  aiienj  extends  from  Poupart's  ligament  to  the  tendinous 
opening  in  the  adductor  magnus  nuiscle,  at  the  junction  of  the  middle 
and  lower  tiiird  of  the  thigh,  in  a  line  drawn  midway  between  the  ante- 
rior superior  spine  of  the  ilium  and  the  symphysis  pubis  and  the  inner 
.side  of  the  internal  condyle. 

(ii)  Tile  common  femoral  artery  extends  from  Pou])art's  ligament  to 
the  origin  of  the  dee])  femoral,  about  one  iiu'li  and  a  half.  It  is  super- 
ficial, lieing  covered  by  the  skin,  supi'rticial  and  deep  fasciie,  and  lym- 
phatic glands  ;  the  vein  lies  on  its  inner  side,  and  the  anterior  crural 
nerve  half  an  inch  to  its  outer  side ;  the  vessels  lie  in  a  canal  formed 
by  the  parting  of  the  two  layers  of  the  fascia  lata,  and  are  separated  by 
this  septum.  Half  or  three-quarters  of  an  inch  below  Poupart's  liga- 
ment will  be  the  most  favorable  locality  for  ligature  (Fig.  253).  The 
pulsation  lieing  recognized  midway  between  the 
anterior  superior  spine  of  the  ilium  and  the 
pubes,  make  an  incision  two  inches  in  length 
over  the  artery,  commenc-ing  over  Poupart's 
ligament  ;  divide  the  skin  and  cellular  tissue  ; 
raise  the  fascia  on  a  director  and  expose  the 
sheath  ;  open  it,  and  examine  iov  the  origin  of 
the  profunda  and  epigastric ;  draw  the  vein  in- 
ward and  pass  the  needle  around  the  artery 
from  within  outward,  ligating  it  above  the  pro- 
funda femoris.  The  incision  has  been  made 
parallel  with  Poupart's  ligament.  In  persons 
of  ordinary  Hcsh  the  fold  of  the  groin  corre- 
.sponds  exactly  with  Poupart's  ligaineiit,  but  in 
thos(>  who  are  very  fleshy  the  fold  is  somewhat 
below  Poupart's  ligament,  and  should  this  be 
taken  as  the  guide  to  the  commencement  of  the 
incision,  there  would  lie  danger  of  applying  tlie 
ligature  just  below  tile  origin  of  the  profunda  ; 
it  is  advisalilc  to  bring  the  ligament  into  view 
before  the  ligature  is  applied,  and  to  pass  the 
needle  a  finger's  breadth  below. 

(b)  The  superficial  femoral  artery  lies  in  a 
ti-iaugle,  Scar])a's  space,  formed  by  Poii]iart's 
ligament  above  as  its  base,  the  sartorius  exter- 
nally, and  the  adductor  brevis  internally  ;  it  is  very  superficial,  lieing 
covered  by  integument,  the  superficial  and  dee])  fasciae,  and  lymphatic 
glands ;  the  vein  is  on  the  inner  and  slightly  |)osterior  jiart  (Fig.  254). 
Abduct  and  })lace  the  thigh  on  its  external  asjicct ;  make  an  incision, 
commencing  about  four  inches  below  Pou])art's  ligament,  along  the  inner 
margin  of  the  sartorius   muscle,  three   inches  in  length  ;  the  saj)henous 


p, - 


1- 
D- 


Ligature  of  right  common  fem- 
oral at  base  of  Scarpa's  tri- 
angle :  A,  line  of  Poupart's  lig- 
ament; /?, superficial  fascia:  C, 
fiiscia  lata;  D,  sheath;  a,  fem- 
oral artery ;  b,  femoral  vein :  c, 
internal  saphenous  vein;  1. 
yeuito-erural  nerve  (Troves). 


■768 


OrmiA TIVE  STJRGER Y. 


Fig.  254. 


vein,  first  made  prominent  by  pressure  above,  is  left  to  the  inner  side; 
divide  tiie  i'aseia  lata,  a,  expose  and  draw   outward  the  sartorius,  h,  and 

the  sheath  of  the  vessels  beeomes  ap- 
parent ;  the  position  of  the  artery  is 
recognized  by  its  pulsations;  open  tlie 
sheatii  to  a  suffieient  extent,  and  then 
pass  the  needle,  very  eautiously,  from 
within  outward  to  avoid  the  vein,  c ; 
tlie  point  of  the  needle  should  be  kept 
close  to  the  artery,  </,  as  the  vein  lies 
,  closely    on    its    inner   and    posterior 
aspect.      If  the    saphenous    vein    is 
wounded,  compression  is  sufficient  for 
itstreatment :  if  the  incision  fallsujmn 
the  sartorius,  this  mustbedrawn  aside, 
(c)  The    portion    of  the   femoral 
artery  at  the  apex  of  Scarpa's  space 
(Fig.  255)  is  covered  by  the  skin,  superficial  and  deep  fascire,  and  sar- 
torius, and  is  contained  in  a  fibrous  canal ;  the  femoral  vein   lies  on  the 

outer  and  posterior  part  of  the 
artery,  and  the  long  saphenous 
nerve  more  externally.  Place  the 
limb  in  position,  and  make  an  in- 
cision three  or  four  inches  in  length 
at  the  middle  of  the  thigh,  on  the 
line  given  or  on  the  inner  l)ordcr 
of  the  sartorius  muscle,  its  upper 
extremity  being  six  lines,  and  the 
lower  two  lines,  from  the  internal 

Fig.  256. 


Femoral  artery  in  Scarpa's  space. 


Fig. 


B-- 


Ligature  of  right  femoral  artery  at  apex  of 
Scarpa's  triangle:  A,  fascia  lata;  B.  sarto- 
rius; C,  adductor  longtis;  />,  sheath  of  ar- 
tery ;  a,  femoral  artery ;  6,  tributary  to  inter- 
nal sai:)henous  vein ;  1,  long  saphenous 
nerve ;  2,  internal  cutaneous  nerve  (Treves). 


The  left  femoral  artery  in  Hun- 
ter's canal :  .s,  sartorius  drawn 
inward  ;  /,  fascia  closing  the 
canal,  opened  freely;  o,  the 
artery,  with  a  small  opening 
iu  its  sheath  for  the  passage  of 
the  needle ;  s.n,  long  saphe- 
nous nerve. 


border  of  that  muscle,  care  being  taken  to  avoid  the  internal  saphenous 
vein,  the  course  of  which  is  made  apparent  by  compression  al)ove  ;  expose 


LIGATURE  OF  AETEPdES. 


769 


the  sartorius  by  dividing  the  f;wcia  lata  ;  draw  it  outward  ;  expose  and 
divide  tiie  fibrous  connection  between  tiie  vastus  and  adductor  muscles  ; 
the  sheath  of  the  vessel  now  appears,  wliich  is  readily  opened,  and  the 
needle  passed  from  within  outward,  avoiding  the  vein  and  long  saphenous 
nerve. 

[d)  At  the  inferior  part  of  its  course  the  femoral  artery  enters  a 
fibrous  sheath  formed  by  the  fibrous  bands   which    extend    from    the 
vastus  internus  to  the  adductor  magnus  and  longus,  having  over  it  the 
sartorius  muscle,  fascia\  and  integuments  (Fig.  '2o(J).     Flex  the  thigh  on 
the  pelvis,  the  limb  resting  on  its  external  surface ;  make  an  incision 
three  inches  long  on  the  outer  margin  of  the  sartorius  innscle,  if  recog- 
nized, or  on  the  line  above  given  ;  the  skin  being  divided,  the  sartorius 
recognize<l,  and  the  fascia  divided  on  a  director,  two  lines  within  its 
external   i^ordei,  draw  the  muscle  backward  and  divide  the  posterior 
part  of  its  sheath  ;  the  s]iace  between  the  vastus  internus  and  adductor 
magnus  is  now  recognized,  which  contains  the  canal  of  the  artery;  open 
this  canal  on  a  director,  and  the  artery  is  exposed,  with  the  vein  on  its 
inside  and  the  saphenous  nerve  on  the  outside ;  the  vessels  are  united  by 
very  dense  cellular  tissue,  and  great  cai-e  is  necessary  to  isolate  the  artery. 
The  poji/ifcnl  nderji  extends  from  the  o]iening  in  the  adductor  mag- 
nus to  the  lower  boixler  of  tiie  po])liteus  nuiscle,  in  an  oblique  direction 
downward  and  outward.      In  the  popliteal  space  the 
external  saphenous  vein  runs  per])endicularly  in  the 
median  line  ;    the  popliteal  nerve  passes  down  the 
middle  of  the  popliteal  space,  superficial  to,  and  on 
the  outside  of,  the  jxipliteal  vessels,  from  which  it  is 
separated  by  adipose  tissue  ;  the  popliteal  artery  is 
covered  in  its  whole  course,  and  crossed  at  the  middle 
of  the  popliteal  space,  by  the  popliteal  vein,  the  di- 
rection of  which  is  vertical ;  the  artery,  always  be- 
neath the  vein,  is  somewhat  internal  to  it  above  and 
external  to  it  lielow  ;  the  vessels  are  covered  supe- 
riorly by  the  Ijclly  of  the  semi-membranosus  ;  below, 
tlicv  pass  between  the  two  heads  of  the  gastrocnemius. 
They  are  connected  tiigether,  thi'oughout  their  course, 
by  dense  cellular  tissue,  which  renders  their  separa- 
tion difficult. 

(a)  In  its  upper  part  make  an  incision  three  inches  in  length,  from 
the  infi'rior  third  of  the  thigh  and  passing  along  the  external  margin  of 
the  semi-meml)ranosus  muscle  ;  divide  the  skin  and  fascia ;  separate  the 
cellular  tissue  with  the  director  and  finger ;  now  flex  the  leg,  and  the 
nerve  first  appears,  then  the  vein  on  its  inside,  and  lastly  the  artery  ; 
pass  the  needle  from  within  outward. 

(b)  In  its  lower  part  (Fig.  2-")S)  the  ])nti<>nt  is  laid  on  his  face,  and  an 
incision  made  througii  the  integument  three  inches  long,  slightly  nn  the 
outside  of  the  median  liiie  ;  the  external  saphenous  vein,  c,  which  lies 
under  the  skin,  is  carefully  avoided  ;  the  fiiscia,  J,  is  divided,  and  the  cel- 
lular substance  in  the  space  between  the  two  heads  of  the  gastrocnemius 
is  separated  with  the  finger,  exposing  the  popliteal  nerve,  1,  the  vein,  h, 
and  most  external,  the  artery,  <i ;  the  nerve  and  vein  are  drawn  inward, 
and  the  needle  is  passed  from  witiiin  outward. 

Vol.  I.— 49 


Left  popliteal  artery  :  .1, 
popliteal  artery ;  1', 
vein  ;  N.  internal  pop- 
liteal nerve ;  M,  biceps 
muscle. 


770 


OPERATIVE  SURGERY. 


Fig.  258. 


The  poderior  tibial  artery,  a  hraiicli  of  the  popliteal  artery,  extends 
from  the  lower  boi'dcr  of  the  poj>liteus  muscle,  in  an  obliipie  direction, 

from  Avithout  inward  to  the  annular  lijja- 
nient ;  its  course  is  in  a  line  commencing  in 
the  centre  of  the  ])opliteal  sjiacc  and  termi- 
nating behind  the  internal  malleolus. 

(«)  In  its  upper  third  the  artery  is 
covered  by  the  tibialis  posticus,  the  deep 
aj)i)neurosis,  the  soleus,  and  the  gastrocne- 
mius. The  liml)  Ijcing  |)laced  on  its  outer 
side,  the  knee  Hexed,  make  an  incision  at 
least  four  inches  in  length,  at  a  distance  of 
'  two-thirds  of  an  inch  from  the  internal 
J3  border  of  the  crest  of  the  tibia  through  the 
integuments  and  deep  fascia  ;  carry  tiie  in- 
dex Hngcr  into  the  wound,  detach  and  push 
(lutward  the  internal  head  of  the  ga.stro- 
cnemius,  and  divide  also  the  attachments 
of  the  soleus,  thus  exposed,  from  the  pos- 
terior surface  of  the  tibia ;  whilst  an  as- 
sistant keeps  this  muscle  held  backward 
and  outward  with  a  blunt  hook,  divide  tlie 
deep  layer  of  aponeurosis  u})on  a  director, 
"i^faseia*-'i'gas?roJnt^^^^^  and  search  for  the  vessel  immediately _be- 

iiteai  artery;  b,  popliteal  vein;  c,  neath  ;  dctach  the  artery,  and  pass  the  liga- 

external  saphenous  vein;   1,  inter-  ,  ,i.,        •,!,!,  ii 

nai   popliteal   nerve;  2,  muscular  ture  ueucatli  it  witli  the  artery  needle. 

branches;    3,    external    saphenous  ^^^  j,j    j^^    ^^^jj^ij^   ^j^j^.^l   ^|-^.   .,,,j^,,,^,  ^^^^^ 

parallel  with  the  inner  border  of  tiie  tibia, 
from  which  it  is  separated  by  the  flexor  longus  digitorum  ;  it  is  cov- 
ered by  the  internal  border  of  the  soleus,  it  has  venae  comites,  and 
the  posterior  tibial  nerve  is  on  its  inner  side.  The  limb  is  placed  as 
in  the  last  position,  and  an  incision  made  three  inches  in  length,  three- 
fourths  of  an  inch  posterior  to  the  internal  border  of  the  tibia ;  the 
integument  and  deep  fascia  being  divided,  the  fore  border  of  the  gastro- 


FiG.  259. 

Divided  tibial  origin  uf 
soleus. 


Ligature  of  the  posterior  tibial  artery  in  its  middle  third. 


cnemius  is  seen  and  drawn  backward,  exposing  the  soleus  ;  the  fibres  of 
this  muscle  should  be  divided  on  a  director ;  the  arterj-  is  now  felt  pul- 


LIGATURE  OF  ARTERIES. 


■71 


sating  about  an  inch  from  tlio  maririn  of'tlu'  tibia  ;  the  pcarl-colorcd  deep 
aponeurosis  which  overlies  is  divided,  and  then  the  muscles  relaxed  bv 
the  position  of  the  limb ;  the  artery  is  isolated  from  its  veins,  the  nerve 
being  pressed  to  the  outside ;  the  needle  is  passed  from  M'ithout  inward 
(Fig:  259). 

(c)  In  its  lower  third  the  artery  passes  behind  the  internal  malleolus, 
at  first  parallel  with  the  tendo  Aehillis,  and  then  midway  between  tiie 
internal  malleolus  and  the  tuberosity 
of  the  OS  calcis ;  it  is  very  superficial, 
and  is  in  relation  anteriorly  with  the 
tendons  of  the  tibialis  posticus  and 
flexor  longus  digitorum,  and  poste- 
riorly witii  the  jiosterior  tibial  nerve ; 
it  has  vena>  comites  (Fig.  260).  The 
leg  being  placed  on  its  external  aspect, 
the  foot  Hexed,  make  an  incision,  two 
inches  in  length,  a  finger's  breadth 
posterior  to  the  inner  edge  of  the 
tibia  and  parallel  with  it ;  the  integu- 
ments are  divided ;  the  deep  fascia 
raised  on  a  direct<ir,  and  a  small  mass 
of  fat  opened,  which  will  expose  the 
artery  and  the  veure  comites  and  the 
jMjsterior  tibial  nerve  ;  the  sheath  of 
tendons  should  lie  carefully  avoided  ;  it  should  be  noticed  that  the  artery 
,sometin\es  lies  anterior  to  the  incision  here  given.  The  artery  may  be 
ligated  a  little  lower  by  making  a  curved  incision 
one-third  of  an  inch  behind  the  external  malleolus. 
At  this  part  of  the  leg  the  anastomoses  of  large 
branches  of  the  internal  saphenous  vein  are  numer- 
ous, and  generally  run  transversely  ;  these  may  be 
brought  out  by  compressing  the  trunk  of  the  vein 
above,  and  thus  be  avoided,  at  least  in  part. 

The  anterior  tibial  artery  emerges  upon  the  an-  C 
terior  part  of  the  leg,  at  its  upper  ]iart,  through  the  i 
interrosseoiis  membrane,  about  the  level  of  the  lower 
margin  of  the  tubei'osity  of  the  tibia,  and  passes 
down  to  the  ankle,  in  a  line  drawn  from  the  inner 
side  of  the  fibula  to  a  point  midway  between  the 
two  malleoli ;  the  anterior  tibial  nerve  is  closely 
applied  to  the  outside  of  the  artery  throughout ;  it 
may  be  ligated  at  any  jioint  in  its  course. 

(a)  In  its  upper  third  ( Fig.  2(51)  the  artery  lies  be- 
tween the  til)ialis  anticus  and  extensor  lontrus  diffi- 
torum,  which  have  their  origin  in  part  from  the  deep 
fascia,  hence  the  intermuscular  septum  is  not  easily 
recognized,  nor  are  the  muscles  readily  separated. 
The  limb  being  turned  inward  and  the  foot  ex- 
tended, take  as  a  guide  the  line  already  given,  or 
a  point  ten  lines  to  tiie  outer  side  of  the  spine  of  the  tibia,  and  make  an 
incision  about  four  inches  in  length  through  the  integument ;  divide  the 


Ligature  of  posterior  tibial  artery  behind 
inner  malleolus. 


Fig.  261. 


-I) 


A — 


Ligature  of  right  anterior 
tibial  artery  (upper  third) : 
A,  faseia  of  leg:  B,  tibialis 
antieus  ;  C,  extensor  com- 
munis digitorum ;  a,  an- 
terior tibial  artery ;  b,  an- 
terior tibial  veins ;  1,  an- 
terior tibial  nerve. 


772 


OPERATIVE  SURGERY. 


(k'Cj)  fascia  witli  a  crucial  incision  to  allow  of  its  complete  sejjaration  ; 
the  intcrniiisciilar  so])tuni  is  now  sought  for,  and  may  he  recognized  :  (1) 
as  the  first  intermuscular  space  from  the  tit)ia  ;  (2)  on  ])ressure  from  witliin 
outward  l)y  tlie  resistance  of  tlie  other  nuiscles  ;  (."])  by  tlie  fact  tliat  at 
the  lower  part  of  tlie  wound  the  wliite  line  of  tlie  muscular  interspace  is 
more  marked.  Tiie  foot  being  flexed,  separate  tiie  nuiscles  with  the  index 
finger,  and,  the  wound  being  held  apart,  expose  the  artery  with  its  two 
veins  and  nerve,  the  latter  being  outside  ;  pass  the  needle  from  without 
inward,  avoiding  the  nerve. 

(//)  In  its  middle  third  tlie  artery  is  covered  by  the  deep  fascia; 
on  the  inner  side  it  has  tiic  tibialis  anticiis  muscle,  and  on  the  exter- 
nal the  extensor  longus  digitorum  and  extensor  ])roprius  pollicis  (Fig. 
2(32).  The  limb  being  placed  as  in  the  former  ])osition,  make  an 
incision  three  inches  or  more  in  length  in  the  course  of  the  artery,  as 
above  given  ;  the  septum  in  the  deej)  fascia 
uniting  the  two  nuiscles  is  recognized  by  a  1"'ig.  26S. 

white  line ;  divide  it  longitudinally  and  also 
by  a  crucial  incision  ;  flex  the  foot  to  relax  <, 

the  muscles,  and,  the  wound  being  separated  ;' 

by  drawing  the  tibialis  anticus,  6,  internally  \ \ 

and  the  extensor  longus  digitorum  and 
extensor  projirius  pollicis  externally,  the 
nerve  is  met  with  more  superficially  than  the 
arter}',  rl,  with  its  veins,  c  ;  pass  the  needle 
from  within  outward,  avoiding  the  nerve, 
(c)  In  its  lower  third  (Fig.  263)  the  artery 

Fig.  262. 


Anterior  tibial  artery  in  its  middle  third. 


Ligature  of  right  anterior  tibial 
artery  (lower  third) :  A,  anterior 
annular  ligament;  B,  tibialis 
anticus :  C,  extensor  proprius 
pollieis;  a,  anterior  tibial  ar- 
tery ;  6,  anterior  tibial  veins ;  1, 
anterior  tibial  nerve. 


is  covered  bv  the  fascia,  and  is  crossed  by  the  extensor  jiroprius  pollicis ; 
it  lies  at  first  between  the  tibialis  anticus  muscle  and  the  extensor  pro- 
prius  pollicis,  the  latter  muscle  crossing  to  the  inner  side  ;  the  artery  lies 
between  the  tendon  of  this  muscle  and  that  of  the  extensor  longus  digi- 
torum ;  it  is  accomjianicd  by  vense  comites  and  the  anterior  tibial  nerve, 
which  here  lies  to  the  outer  side.  The  leg  being  jtlaced  in  a  horizontal 
position,  the  foot  extended,  and  the  tibialis  anticus  nuiscle  recognized, 
make  an  incision  along  the  external  border  of  that  muscle,  on  the  line 
already  indicated,  three  inches  in  length,  but  not  extending  to  the  annu- 
lar ligament ;  carefully  incise  the  deep  fascia  on  a  director,  and  find  the 
space  between  the .  tibialis  anticus  and  extensor  jjroprius  pollicis,  and 


RESECTION  OF  BONES. 


773 


separate  the  two  muscles  with  the  index  fingei- ;  now  flex  the  foot,  and 
ex]iose  the  arterv  restino;  on  the  tibia  with  the  nerve  snjierficial  to  it ; 
isolate  it  from  the  two  veins,  and  ]>ass  the  needle  from  witiiin  outward, 
the  nerve  being  drawn  iuward.  if  the  incision  falls  between  the  exten- 
sor proprius  poUiois  muscle  aud  the  extensor  couununis  digitoruni,  the 
ligature  may  still  be  applied. 

The  dorsalis  pedis  artery  terminates  the  anterior  tibial,  and  runs  in 
a  line  drawn  from  the  middle  of  the  intermalleolar  space,  measured 
from  tlie  extremities  of  the  malleoli,  to  the  space  between  the  first  meta- 
tarsal l)oues.  It  is  covered  by  the  integuments,  fascia,  and  innermost 
tendon  of  the  extensor  brevis  digitdruni ;  ou  its  iuner  side  is  the  exten- 
sor proprius  poUicis,  and  externally,  the  inner  tendon  of  the  extensor 
longus  digitoruni ;  on  its  external  aspect  is  the  anterior  tibial  nerve. 
Make  an  incision  (Fig.  264)  two  or  three  inches  in  length  parallel  to  the 


Fig.  264. 


Exlensor 

brevin  digitoruuiTjf^' 
muscle. 


external  border  of  the  tendon  of  tiie  extensor  proprius  pollicis  muscle  ; 
divide  the  skin  and  deep  fascia  on  a  director,  and  draw  the  internal 
division  of  the  extensor  brevis  digitoruni  outward,  exposing  tiie  arterv 
and  its  accompanying  veins ;  the  nerve  is  on  the  outside ;  pa.ss  the  needle 
from  within  outwanl. 


The  Resection  op  Bones. 

Resection  of  a  bone,  in  part  or  wiiolc,  is  required  after  injuries  which 
have  destroyed  its  vitality,  or  after  diseases  which  have  resulted  in  caries 
or  necrosis,  or  in  the  removal  of  tumors  ;  but  the  oi)eration  is  justifiable 
only  when  it  is  evident  that  resection  is  preferable  to  every  othei" 
remedial  measure.  When  inidertaken  it  must  be  so  planned  and 
executed  as  to  become  tiie  first  step  in  a  process  of  repair  by  which 


774 


OPERATIVE  SURGERY. 


a  part  that  would  otherwise  have  been  sacrificed  is  restored  to  more  or 
less  cdinplete  nsefiihiess.  Tiie  operation  must  be  determined  by  the 
cimdition  of  tlie  ]iatient  and  of  tlie  diseased  part.  As  a  rule  the  opera- 
tion is  indicated  only  wlien  the  fryneral  hcaltli  admits,  for  if  the  patient 
is  suti'ering  from  a  progressively  wasting  disease,  as  tuberculosis  or 
marasmus,  which  will  necessarily  prove  fatal,  resection  would  be  unwise, 
as  repair  would  not  follow.  In  injuries,  as  gunshot,  only  such  frag- 
ments of  bone  should  be  removed  as  are  nearly  or  fpiite  detached  from 
the  periosteum.  In  caries  of  a  hollow  bone  the  ulcer  may  be  tlioroughly 
cleaned  out  witli  the  gouge  and  the  cavity  be  allowed  to  close  by  gran- 
ulation, but  if  the  bone  is  small  extirpation  may  be  necessary  to  arrest 
the  process  at  once.  If  a  hollow  bone  is  affected  throughout,  as  with 
periostitis,  external  and  internal  caries,  or  partial  internal  and  external 
necrosis,  extirpation  of  the  entire  bone  may  be  required  as  the  only 
alternative  of  amputation.  Tumors  of  bone,  if  not  malignant,  must  be 
removed  from  their  locality,  but  if  malignant,  extirpation  of  the  bone 
or  wide  resection  is  necessary. 

Resection  of  a  joint  is  necessary  for  such  shot  injuries  as  the  commi- 
nution of  the  ends  of  the  bones,  or  tlie  impaction  of  a  ball  in  the  end  of 
tlie  bone  in  such  manner  that  it  cannot  be  removed  without  destruction 
of  the  bone  ;  in  compound  dislocation  with  extensive  injury  of  the  soft 
parts,  or  complicated  with  fracture,  and  in  caries  which  has  destroyed 
the  articular  surface  and  continues  to  progress  in  spite  of  well-directed 
efforts  to  control  it.  Compound  dislocations  and  fractures  involving 
joints,  once  so  fatal  from  inflannnation,  do  not  now  always  necessitate 
excision,  for  when  antiseptic  methods  are  rigidly  enforced  from  the  first 
suppuration  does  not  occur. 

Tlie  fimc  of  operating  after  an  injury,  as  a  gunshot,  should,  if  pos- 
sible, be  within  twenty-four  hours  of  the  accident,  or  primary ;  if  it  is 
delayed  beyond  this  period,  it  sliould  not  be  performed  until  the  inter- 
mediary stage  of  inflammation  is  passed.  If  the  bone  is  necrosed,  the 
rule  should  be  not  to  attempt  removal  laefore  complete,  or  nearly  com- 
pleted, detachment,  because  the  dead  bone  can  rarely  be  taken  out  with- 
out removing  healthy  and  newly-formed  bone,  and  the  new  bone  is  not 
firm  enough  before  the  sequestrum  is  detached. 

The  ■instrimienfs  required  in  resection  and  excision  may  be  few  or 
many,  both  in  number  and  variety,  according  to  the  nature  of  the  case. 
(1)  The  knife  (Figs.  265  and  266)  should  be  broad  and  firmly  set  in 

Fio.  265. 


Fir,.  2m. 


Scalpels 


a  rough  handle,  which  mav  or  may  not  terminate  in  a  periosteotorae 
(Fig.  266).  (2)  The  retractors  may  consist  of  broad  metal  plates 
properly  curved    (Fig.   267)   or  take"  the   form    of  hooks;   the    latter 


RESECTION  OF  BOXES. 


775 


Fio.  267. 


are  less  liable  to  slip  out  of  the  wound,  but  do  not  so 
effectually  open  it.  (3)  Tlie  periosteotome  takes  many 
forms  (Figs.  268,  269);  it  is  always  a  blunt  instrument, 
and  in  its  use  care  must  be  taken  not  to  contuse  the  peri- 


FiG.  2G8. 


Fi«.  21)9. 


Retractor.  IV'riDstrotunics. 

osteum  when   it  is  desirable  to  preserve  its  function.     (4)  The  bone- 
cutting  instruments  are  numerous  and  important.     The  straight  bone  for- 

FiG.  270.  Fig.  271.  Fig.  272.  Fig.  273.  Fig.  274. 


Fig.  275. 


CuttiiiK  ffroeps. 

ceps  (Fig.  270)  is  a  most  useful  instrument  in  the  section  of  the  small  bones 
wherever  it  can  be  brouglit  to  bear.  But  frequently  it  is  quite  difficult 
to  roach  tiie  part,  which  may  be  more  readily 
divided  with  the  forceps  than  the  saw  unless 
the  blades  are  curved  at  a  considei'able  angle  ; 
in  such  cases  a  forceps  curved  (Figs.  271  or 
272)  will  lie  found  serviceable.  The  bone- 
gnawing  forceps  (Figs.  273,  274),  or  rongeur, 
is  indispensable  in  many  resections,  as  it 
enables  the   operator  to    remove  projecting 

?arts  not  accessible  to  otlier  instruments, 
"he  saw  in  one  of  its  various  forms  is  neces- 
sary. Tiie  chain  .saw  (Fig.  275)  consists  of 
a  number  of  pieces,  with  movable  artic- 
ulations, terniinatc'(l  at  each  extremity  by 
handles  with  whicii  it  is  worked.  To  use 
this  saw,  one  handle  is  removed  from  tiie 
hook,  and  a  needle,  armed  with  a  strong 
thread,  is  attached  to  the  end  ;  the  needle 
is  passed  under  the  bone,  and  the  saw  drawn 
into  its  jwsition,  with  the  cutting  edge  up- 
Mard,  and  the  liandle  is  tiien    re-attached;  ihainsuw. 


776 


OPERATIVE  SUEGERY. 


the  operator,  grasping  the  handles,  draws  the  saw  alternately  from  side 
to  side,  until  the  bone  is  divided  :  there  is  great  danger  of  breaking  this 
saw  if  it  is  worked  carelessly;  it  should  l)e  drawn  from  side  to  side 
steadily,  at  an  angle  of  45°  to  the  long  axis  of  the  bone.  The  sections 
may  consist  of  metallic  Iteads  strung  on  a  wire  with  handles  ;  such  a 
saw  will  act  efficiently  in  whatever  direction  it  is  held. 

Other  saws,  of  pecadiar  shape,  arc  often  useful   in  the  removal  of 
certain  bones,  though  not  absolutely  essential ;  the  saw  (Fig.  276)  with 

Fjo.  276. 


Saw  with  movable  back. 


a  movable  back  may  be  used  to  advantage  in  most  resections  of  bones 
of  the  extremities ;  in  the  removal  of  the  superior  maxilla  the  right  and 
left  bone  saws  (Figs.  277,  278)  enable  the  operator  to  separate  its  supe- 


FiG.  277. 


Fig.  278. 


Right  and  left  sa\v.s. 


rior  attachments  with  great  fiicility ;  a  small  straight  saw  (Fig.  279)  is 
often  recpiired,  and  when  it  is  necessary  to  use  a  part  of  the  edge  an 
india-rubber  tube  may  be  drawn  over  the  part  unused  to  prevent  its 


Fig.  279. 


Fig.  280. 


L....A 


straight-back  saw. 


Hey's  saw. 


injuring  the  soft  parts ;  occasionally  a  saw  having  a  circular  as  well  as  a 
straight  edge  (Fig.  280)  is  required  in  removing  sharp  ])oints  or  thin 
bones ;  a  saw  concealed  in  a  sheath  is  very  useful  in  subcutaneous 
division  of  bones  (G.  F.  Shrady) ;  finally,  a  saw  is  essential  which  may 
be  taken  from  its  position  (Fig.  281),  where  it  is  firndy  held  by  a  spring 
connected  with  the  handle,  and  passed  under  the  bone,  if  required,  and 
the  ends,  being  re-attached  in  the  frame,  the  bone  is  as  readily  divided 
from  beneath  as  from  above  ;  the  saw  may  be  turned  laterally  also  or  be 
made  to  cut  in  a  curve ;  the  tension  of  the  saw  is  regulated  by  a  spring 
enclosed  in  the  handle.  Bone  drills  for  the  introduction  of  the  wire 
suture  must  be  provided,  and  an  osteotrite  will  often  l)e  necessary  (Fig. 
282).     The  gouges,  the  chisel  (Fig.  283),  and  the  mallet  (Fig.  284),  are 


RESECTION  OF  BONES. 


777 


often  required  ;  to  thorouglily  clean  out  all  forms  of  carious  cavities  two 
or  more  gouges  and  spoons  arc  necessary  with  different  cutting  edges ; 


Fig.  281. 


Butcher's  saw. 


the  mallet  may  be  of  wood  or  metal  with  a  firm  handle.     (5)  The  seizing 
forceps  may  be  the  common  dressing  forceps  (Fig.  285)  for  small  frag- 


Fifi.  282. 


Drills. 


ments,  and  larger  furceps  for  large  fragments  (Fig.  286) ;  they  should 
also  have  straight  and  curved  beaks  (Figs.  287,  288)  to  seize  fragments 


Fig.  283. 


Chisel  and  gouges  vviili  udjustal>lu  liandlu. 


Fig.  284. 


M 


Mallet. 


that  are  concealed.     The  bone  scoop  (Fig.  289)  is  neces.sary  in  removing 
all  the  dead  tissues  in  bone-eavities. 

An  instrument  capable  of  seizing  the  bone  and  holding  it  in  position 


778 


OPERATIVE  SURGERY. 


while  ii  saw  adjusted  in  it  can  be  so  operated  as  to  divide  the  bone  is 
often  desirable.     Such  an  instrument  has  been  devised,  and  in  modified 


Fig.  285. 


Fig.  286. 


Fig.  287. 


Fig.  288. 


r  creeps. 


form  (Fig.  290)  has  proved  very  useful.     It  consists  of  handles  having 
a  fixation  clamp,  /;  by  opening  or  closing  the  handles  the  jaws,  g,  ai'e 


Fig.  289. 


G.T\«^^UU.&  CCl 


Bone  scoop. 


separated  or  closed ;  the  saw,  I,  is  in  shape  like  a  chisel  and  works  in  a 
shield,  h.     The  bone  to  be  exsected  having  been  exposed,  with  its  peri- 


Fig.  290. 


Combined  forceps  and  saw  (Wyeth). 


o,steum  peeled  off  in  common  with  all  the  circumjacent  tissues,  the  ope- 
rator, holding  the  handle  uf  the  instrument  in  his  left  hand  (the  saw 


RESECTION  OF  BONES.  779 

being  entirely  removed),  opens  the  jaws,  g,  wide  enough  to  insinuate 
them  about  tiie  bone ;  as  soon  as  this  is  aceomjilished,  witii  the  right 
hand  slide  the  saw  into  the  shield,  /*,  down  until  the  teeth  engage  against 
the  bone;  a  slight  oscillation  of  the  handle  of  tiie  saw  with  recjuisite 
pressure  carries  it  through  the  bone  with  remarkable  rapidity  and  with- 
out wounding  or  bruising  the  contiguous  soft  tissues. 

The  preparations  for  the  operation  are  as  follows :  Cleanse  the  hands 
and  nails  with  soap,  water,  and  nail-brush  and  wash  them  in  liichloride 
solution  ;  put  the  instruments  in  the  tray  and  cover  tiieni  with  carbolic- 
acid  solution  1  :  20  ;  prepare  the  solution  of  bichloride,  1  :  2000,  in  the 
irrigator,  the  water  being  hot.  The  parts  to  be  operated  should  l)e  anti- 
septically  prepared  on  the  preceding  day,  and  wrapped  with  aseptic 
dressings.  Bind  towels,  wrung  out  of  the  bichloride  solution,  around  the 
limb,  one  above  and  one  below  the  point,  and  spread  others  over  all  the 
region  of  tiie  wound,  so  as  to  protect  the  hands  and  instruments  from 
contact  with  soiled  surfaces  or  materials.  Apply  the  elastic  bandage 
luiless  tlie  parts  are  infiltrated  with  pus. 

The  operation  is  as  follows :  (a)  In  the  removal  of  the  bone  the 
method  of  operating  must  be  adapted  to  each  particular  case.  In  shot 
fractures  the  extirjxition  of  fragments  must  be  through  openings  extend- 
ing from  tiie  wound  ;  in  necrosis  tiic  sinuses  are  iiiiides  for  incisions  :  in 
the  e.Kcision  of  the  bone  for  morbid  growths  the  incisions  must  l)e  largely 
in  the  direction  of  the  tumor.  The  incision  in  general  should  be  made 
as  nearly  as  possible  over  the  bone  to  be  removed  and  parallel  with 
arteries,  nerves,  and  muscles.  The  soft  parts  should  not  be  destroyed, 
e.xcept  so  far  as  they  have  undergone  degeneration  or  interfere  witJi  the 
proper  closure  of  the  wound.  Injuries  to  lilix id- vessels  and  nerves  lying 
in  the  track  of  the  incision  should  lie  scn-upulously  avoided  by  drawing 
them  aside;  muscles  and  tendons  siiould,  if  possilile,  not  he  divided  nor 
their  attachments  incised,  but  should  be  separated  to  the  necessary  extent 
with  a  blunt  instrument.  The  bone  being  exposed,  the  operator  should 
preserve  in  the  wound,  and,  as  far  as  possible,  in  its  original  position,  the 
periosteum  of  the  bone  to  be  removed,  in  order  to  the  rejirodiiction  of 
suftlcient  new  bone  to  preserve  the  function  of  the  part.  The  periosteum 
is  best  jireserved  by  first  incising  it  to  the  extent  of  the  bone  to  be  re- 
moved, and  then  separating  it  with  tlie  periosteal  knife  or  the  end  of  the 
scalpel.  Tiie  periosteum  being  separated,  the  bone  must  be  divided  by 
cutting  forceps  or  the  saw,  and  each  jiortion  separately  removed  ;  if  the 
saw  is  used,  the  soft  parts  should  lie  cait'fuily  protected  by  compresses  or 
a  spatula  introduced  underneath  the  bone.  In  some  eases  the  interior  of 
carious  caiiceliatetl  bones  may  be  scooped  out  and  the  external  shell  be 
left  as  the  basis  of  new  bone.  The  scoop  may  be  a  curved  chisel,  the 
periosteal  knife,  or  other  instrument  which  can  be  applied  to  the  inte- 
rior of  the  carious  cavity. 

(fj)  In  the  resection  of  joints  the  operator  should  aim  (1)  to  remove  all 
diseased  structures  withdtt  needlessly  sacrificing  jiarts  ;  in  children,  espe- 
cially, the  epiphyses  of  bones  must  be  preserved  with  the  most  scrupu- 
lous care,  to  ensure  their  future  growth ;  in  adults  the  amount  of  bone 
removed  will  always  have  regard  to  the  future  usefulness  of  the  joint. 
(2)  If  the  functions  of  the  joint  are  to  be  preserved,  as  of  the  upper  ex- 
tremities, the  fibrous  structures  must  be  saved  in  their  projier  relations ; 


780  OPERATIVE  SURGERY. 

the  periosteum  must  be  preserved  wit li  tlic  attacliniciits  to  tlic  capsule; 
tlic  muscular  attaciiuieut.s  must  lie  separateil  uuinjureil  or  witli  the  bony 
fraaineuts  (if  their  insertidus,  to  ensure  tiieir  future  usefuluess  ;  the  Ijones 
may  be  so  sJuqx'd  and  placed  in  position  as  to  maintain  their  s])ecial 
movements,  preserving  even  a  useful  hinge-joint  at  tiie  elljow.  (3)  If  the 
joint  is  to  be  ankylosed,  as  tiie  knee,  the  surfaces  of  the  excised  bones 
must  be  accurately  applied  and  maintained  to  secure  firm  union.  The 
bones  may  be  maintained  in  apj)osition  by  wire,  catgut,  prepared  silk, 
and  by  nails  and  metallic  jiins  driven  through  the  fragments.  The  silver 
M'ire  is,  in  general,  the  best  material  for  that  purpose.  It  should  be  so 
inserted  as  not  to  recjuire  removal — viz.  after  being  twisted,  cut  it  off  and 
turn  the  twisted  ends  downward  between  the  extremities  of  the  bones. 

The  treatment  of  resection  wounds  should  secure  rest,  and  free- 
dom from  irritation.  Rest  is  obtained  by  a])])aratus  adapted  to  each 
case;  in  general  the  immovable  apparatus  of  plaster  of  Paris  is  most 
availal)le  and  useful.  Tliough  these  wounds  usually  heal  liy  granula- 
tion, yet  by  carefid  attention  to  the  use  of  antise})tics  suppuration  may 
be  entirely  prevented.  They  are  peculiarly  liable  to  be  poisoned  by 
septic  ferments  from  the  putrefactive  matters  already  existing  in  the 
wound.  The  dressings  shoidd,  therefore,  be  scru])ulously  antiseptic 
throughout  the  stage  preceding  granulation  and  subsequently  to  such 
degree  as  will  jirotect  the  granulations  from  any  infectious  matter  which 
may  enter  or  form  in  the  wound.  Irrigate  the  wound  after  the  operation 
with  bichloride  solution,  1  :  2000  ;  remove  every  particle  of  dead  tissue  ; 
apply  drains  to  every  recess  which  will  retain  fluids  ;  and  close  the  wound 
with  sutures  to  the  fullest  extent  practicable.  Ajtjily  iodoform  dressings 
covered  with  bandages  of  bichloride  or  earbolized  gauze,  and  finally  two 
or  three  layers  of  plaster-of- Paris  bandages.  Pe-drcss  at  intervals  of 
several  days  only,  or  when  there  are  indications  of  disturbances  in  the 
wound. 

BOXES    AND    JOINTS    OF    THE    UPPER    EXTREMITIES. 

Resection  is  to  he  preferred  to  amjiutation  in  the  greater  muiiber  of 
lesions  of  the  upper  extremities,  as  the  princijial  ftmetion  involves  that 
of  mobility. 

The  phalanges  may  be  resected  in  part  or  whole,  but  the  results  are 
not  always  favorable,  owing  to  the  stiffness,  shortening,  and  deformity 
which  so  often  follow.  The  incisions  should  be  on  the  side  of  the  joints 
to  be  excised.  Efforts  should  be  made  to  preserve  the  periosteum  with  a 
view  to  the  ]>roduetion  fif  new  bone  in  the  shafts  of  the  bones  that  have 
been  removed.  In  the  after-treatment  apply  a  splint  to  the  palmar  sur- 
face, and  make  such  extension  as  will  maintain  the  full  length  of  the 
j)halanx.  The  entire  phalanx  is  removed  by  an  incision  over  the  shaft 
of  the  bone  on  the  side  ;  the  tendons  being  raised,  introduce  the  bone 
forceps,  divide  the  bone,  and  remove  the  two  halves  sejiaratelv  at  their 
articulation.  In  removing  the  third  or  ungual  jihalanx  make  on  the 
palmar  surface  a  doul)le  T-ineision,  one  end  Corresjxmding  to  the  artic- 
ulation, the  other  to  the  extremity  of  tiie  finger;  denude  the  phalanx 
from  the  end  toward  its  base,  the  nail  remaining  intact. 

The  Metacarpal  Bonesi. — The  superficial  condition  of  the  dorsal 
aspect  of  these  bones  and  the  important  anatomical  relations  of  their 


RESECTION  OF  BONES. 


781 


palmar  surfaces  require  that  all  operations  for  their  excision  be  com- 
menced on  the  posterior  part  or  dorsum. 

(«)  The  entire  bone  is  removed  as  follows :  Make  an  incision  along 
the  dorsal  surface  of  the  tliird  and  tlmrth  metacarpal  liout's,  avoidinji' 
the  extensor  tendons,  and  on  the  radial  siile  of  the  second  antl  ulnar  side 
of  the  fifth  ;  draw  the  extensor  tendon  on  one  side  and  relieve  the  sides 
of  the  bone  of  the  soft  parts ;  separate  the  periosteum  as  much  as  possi- 
ble and  divide  the  centre  with  the  bone 

forceps  (Fill'.  291)  or  with  the  chain  saw,  Fk;.  292. 

the  soft  parts  being  protected  by  a  com- 
press or  spatula  ;  the  fragments  arc  then 
separately  elevated,  and  disarticulated 
with  the  point  of  the  knife  (Fig.  292).  c^^. 

This  operation  may  be  variously  modi- 


Resection  of  metacarpal  bone. 


Resection  i.>f  the  proximal  end. 


fied,  according  to  the  condition  of  the  ]iart  affected.  Wlien  there  is 
nuich  swelling  make  a  short  lateral  incision  at  each  extremity  of  the 
longitudinal  cut.  The  incision  may  also  be  made  lietwecn  the  tendons 
of  the  long  and  short  extensors  on  the  dorsum  along  the  radial  border. 
In  resection  of   the  metacarpal  the  cut  may  be  a  T  or  an  L. 

(6)  The  shaft  is  removed  by  a  longitudinal  incision  on  the  radial 
border  of  the  first  and  second,  on  the  ulnar  border  of  the  fifth,  and  the 
dorsal  surface  of  the  third  and  fourth  ;  carefully  avoid  the  extensor 
tendons,  and  with  a  chain  saw  or  cutting  forceps  divide  at  two  points 
the  denuded  bone. 

(c)  The  proximal  portion  of  the  bone  is  resected  by  a  longitudinal 
incision  over  the  upper  extremity  of  the  metacarpal  bone ;  avoid  the 
extensor  tendon,  separate  the  soft  ]iarts  from  the  sides  of  the  bone ; 
divide  the  bone  at  the  rec[uisite  point  witli  bone  forceps  or  witli  the 
.saw,  after  being  isolated  from  the  soft  parts,  and  as  far  as  ]>ossible 
from  the  periosteum  ;  seize  the  fragment  with  the  forccjis ;  rai.se  it 
from  its  bed  (Fig.  292),  and  disarticulate  the  joint  with  the  point  of 
the  knife. 

{d)  In  complete  resection  the  extremity  of  the  metacarpal  lione  and 


782  OPERATIVE  SURGERY. 

its  correspondinir  cari):!!  Iionc  miv  removed  by  a  single  longitudiiuil 
incisidii  made  over  tiie  superior  extremity  of  the  met!iear]);il  Ixiiie,  wiiich 
is  deinided  of  soft  parts  and  siiwii  at  tiie  ))ro]K'r  ])(iiiit  ;  remove  tiiis 
part  at  its  articulation,  and  then  extirpate  the  earj)al   l)one. 

{e)  The  phalangeal  extremity  of  the  metacarpal  bone  (jf  the  thumb 
is  removed  thus  :  Make  an  incision  on  its  dorsal  surface ;  draw  aside  the 
extensor  tendons  carefully  ;  divide  with  a  chain  saw  at  the  proper  point ; 
seize  the  diseased  jxirtion  with  the  forceps,  bring  it  forward  and  expose 
the  articular  extremity  with  the  point  of  the  knife,  by  wliich  it  is  readily 
disarticidated. 

The  phalangeal  joinh  .should  be  excised  by  an  incision  along  the  side, 
sliglitly  convex  downward ;  through  a  single  incision  the  extremities  of 
the  bones  may  often  be  reached  and  excised  by  turning  them  outward. 
In  the  treatment  make  sufficient  extension  by  means  of  a  palmar  splint 
to  keep  tlie  bones  apart,  and  l)egin  jiassive  flexion  as  soon  as  repair  is 
established. 

The  inefacarpo-jjiia/a iii/cal  jointu  should  be  excised  by  dorsal  incisions 
along  the  margin  of  the  extensor  tendons,  which  must  be  drawn  on  one 
side  ;  the  articular  surfaces  being  cleared,  excise  them  with  cutting  for- 
ceps, a  fine  saw,  or  chain  saw.  The  treatment  is  the  same  as  after  ex- 
cision of  the  phalangeal   joints. 

The  irrlxt-joiiit  is  j)roperly  limited  to  the  articular  end  of  the  radius 
and  the  first  row  of  earpals.  But  excision  at  the  wrist  includes  the 
removal,  not  only  of  the  radius  and  first  row  of  carpal  bones,  but  of 
a  part  or  whole  of  the  ends  of  the  radius  and  ulna,  a  part  or  M'hole 
of  the  carpus,  the  proximal  ends  of  the  metacarpal  bones,  or  all  of  these 
at  once.  The  radio-carpal  articulation  is  formed  between  the  radius 
and  triangular  fibro-eartilage  above  and  tlie  scaphoid,  semilunar,  and 
cuneiform  bones  below ;  the  carpal  articidations  are  arthroidal  ;  the 
synovial  sacs  are  so  arranged  that  their  communications  are  limited : 
this  anatomical  peculiarity  should  be  remembered  in  the  eflbrt  to  remove 
portions  of  the  carpus,  as  it  is  desirable  not  to  open  these  cavities  far- 
ther than  is  absolutely  necessary  ;  the  ligaments  are  dorsal,  palmar,  and 
interosseous. 

There  are  several  methods  of  operation,  but  those  devised  by  Lister, 
Oilier,  and  Boeckel  are  to  be  preferred. 

(a)  Lister's  excision  of  the  entire  M'rist  consists  of  a  series  of  opera- 
tions, each  of  which  must  be  executed  with  scrupulous  care,  as  follows : 
Break  down  adhesions  of  tendons  l)y  freely  moving  all  the  articulations 
of  the  hand  ;  commence  the  first  incision  at  the  middle  of  the  dorsal 
aspect  of  the  radius,  A  (Fig.  293)  on  a  level  with  the  styloid  ])rocess; 
carry  it  toward  the  inner  side  of  the  metacarpo-phalangeal  articulation 
of  the  thumb,  running  jiarallel  in  this  course  to  the  extensor  secundi 
internodli ;  on  reaching  the  line  of  the  radial  border  of  the  second  meta- 
carpal bone  carry  it  downward  longitudinally  half  the  length  of  the 
bone,  the  radial  artery  lying  tiirther  to  tlie  outer  side  of  the  limb  ;  detach 
the  soft  parts  from  the  bone  at  the  radial  side  of  tlie  incision,  the  knife 
being  guided  by  the  thumb-nail ;  divide  the  tendon  of  the  extensor  carpi 
radialis  longior  at  its  insertion  into  the  base  of  the  second  metacarpal 
bone,  and  raise  it  along  with  that  of  the  extensor  carpi  radialis  brevior, 
previously  cut  across,  and  the  extensor  secundi  internodii,  while  the  radial 


RESECTION  OF  BONES. 


783 


im^(^'' 


Excision  of  wrist:  ^,  Lister's  radial  incision; 
B,  Lister's  ulnar  incision ;  C,  Oilier ;  D, 
Boeekel. 


is  thrust  some'what  outward ;  separate  the  trapeziinn  from  the  rest  of  the 
carpus  by  cuttiug  forceps  apjtlicd  in  tlie  line  M'ith  the  lougitudinal  part 
of  the  incision ;  leaving  the  trape- 
zium in  position  until  the  rest  of  Fi<*.  293. 
the  carpus  is  taken  away,  dissect 
the  soft  parts  on  the  ulnar  side  of 
the  incision  from  tlic  carpus  as  far 
as  convenient,  tlic  hand  hcing  bent 
back  to  relax  the  extensor  tendons 
of  tiie  iingers ;  commence  the  sec- 
ond incision,  B  (Fig.  293),  on  the 
palmar  surface,  at  least  two  inches 
above  the  end  of  the  ulna,  imme- 
diately anterior  to  the  bone,  and 
carry  it  downward  between  the 
bone  and  flexor  carpi  ulnaris,  and 
on  in  a  straight  line  as  far  as  the 
middle  of  tlie  ttfth  metacarpal  bone 
on  its  pahnar  aspect ;  raise  the 
dorsal  lip,  cut  tiie  extensor  carpi 
ulnaris  at  its  insertion  into  the 
lifth  metacarpal  bone,  and  dissect 
it   from    its   groove    in    the    ulna 

without  isolating  it  from  the  integuments ;  separate  the  extensors  of  the 
fingers  from  the  carpus,  and  divide  the  dorsal  and  internal  lateral  liga- 
ments of  the  wrist-joint ;  leave  the  connections  of  the  tendons  witii  tiie 
radius  undisturbed  ;  now  clear  the  anterior  surface  of  the  ulna  bv  cutting 
toward  the  l)one,  avoiding  the  artery  and  nerve;  open  tlie  articulation 
of  the  pisiform  bone,  and  separate  the  flexor  tendons  from  the  car- 
pus, the  hand  being  depressed  to  relax  them  ;  clip  througli  the  base  of 
the  process  of  the  unciform  bone  with  pliers,  but  avoid  carrying  the 
knife  tartiier  down  the  hand  than  the  bases  of  the  metacarpal  bones  ; 
divide  the  anterior  ligament  of  the  wrist-joint ;  separate  the  carpus  from 
the  metacarpus  with  cutting  j)liers,  and  extract  the  carpus  with  setpies- 
trum  forceps  through  the  ulnar  incision,  dividing  any  ligamentous 
attachments ;  the  articular  ends  of  the  radius  and  ulna  may  be  pro- 
truded at  the  ulnar  incision  and  excised ;  divide  the  ulna  obliquely  with 
a  small  saw  so  as  to  take  away  the  cartilage-covered  rounded  part  over 
which  the  radius  sweeps  while  the  base  of  the  styloid  process  is  retained  ; 
clear  the  radius  sulKciently  to  remove  the  articular  surface  ;  if  the  caries 
is  slight,  remove  a  thin  slice  without  disturbing  the  tendons  in  their 
grooves  on  the  back  of  the  bone ;  clip  away  the  articular  facet  of  the 
ulna  with  bone  forceps  applied  longitudinally  ;  if  the  caries  is  extensive, 
remove  freely  all  the  diseased  bone  with  pliers  and  gouge  ;  examine  the 
metacarpal  lioiies  and  excise  the  articular  surfaces  only  if  they  are  sound, 
and  more  extensively  if  diseased  ;  next  seize  the  trapezium  with  strong 
f()rce])s,  and  dissect  it  out  without  cutting  the  tendon  of  the  flexor  carpi 
radialis,  and  excise  the  end  of  the  metacarpal  bone  ;  clip  ott'  the  articular 
facet  of  the  pisiform  bone,  and,  if  sound,  leave  the  remainder  in  position  ; 
close  the  radial  incision  firmly  throughout  with  sutures,  and  also  the  ends 
of  the  ulnar  incision,  but  the  middle  must  be  kei)t  open  by  pieces  of  lint 


784 


OPERATIVE  SURGERY. 


introduced  lightly  to  give  support  to  the  extensor  tendons  and  afford  free 
escape  of  discharges. 

(b)  In  Bocckcl's  operation  tlic  iiicisidu  may  l)c  made  fnmi  the  middle 
of  the  ulnar  l)ordcr  of  the  nietacar|)al  bone  of  tlie  index  linger  upward 
to  the  middle  of  the  dorsal  surface  of  the  c})iphyses  of  the  radius,  1) 
(Fig.  293),  crossing  to  the  ulnar  side  of  the  extensor  carpi  ulnaris  at  its 
insertion  into  the  base  of  the  third  metacarpal  bone,  and  dividing  the 
dorsal  ligament  of  the  carpus  between  the  tendons  of  the  long  extensor 
of  the  tlannl)  and  the  extensor  indicis  ;  the  soft  parts  l)eing  raisi'd 
through  this  incision  by  careful  mani[)ulation  (jf  tlie  liand,  the  carpal 
bones  may  be  removed,  one  by  one,  by  dividing  the  ligaments  which 
bind  them  together  and  to  other  bones. 

(c)  Oilier  makes  an  incision,  ('(Fig.  293),  from  an  inch  below  the 
styloid  }>rocess  of  the  radius  upward  along  the  external  l)order  of  that 
bone,  to  a  sufficient  extent ;  a  brancli  of  the  radial  nerve  being  pre- 
served, the  extensor  tendons  of  tlie  thumb  arc  exposed  and  drawn  aside 
and  the  insertion  of  the  superior  longus  exposed.  A\'ith  a  pcriosteotome 
detach  the  tendon  of  the  supinator ;  denude  the  end  of  the  radius  of  the 
periosteum  and  bend  the  carpus  forcilily  inward,  dislocating  the  head  of 
the  radius  outward.  After  separating  the  fibrous  attaclnncnts  excise  the 
requisite  amount.  Tlie  end  of  the  ulna  may  be  reached  through  the 
same  wound,  or  an  incision   along  the  inner  border  will  expose  it. 

The  after-treatment  must  be  pursued  with  due  recognition  of  the 
fact  that  the  new  joint  at  the  wrist  is  produced  by  an  ajiproximation  of 
the  bones  of  the  forearm  and  of  the  metacarpus,  partly  by  shortening 
of  the  limb  and  partly  by  the  growth  of  new  bone  from  the  divided 
ends ;  with  projjer  care,  perfect  symmetry  of  the  liand  can  always  be 
ensured,  for  as  tiie  radius  and  ulna  aliove  and  the  metacarpus  below  are 
divided  in  parallel  lines,  the  shrinking  of  the  new  material  between 
them  draws  the  hand  equally  upward  toward  the  ftu'earm  :  the  surgeon 
should  aim  to  maintain  flexibility  of  the  fingers  by  frequently  moving 
them,  and  at  the  same  time  to  procure  firmness  of  the  wrist  by  keeping 
it  securely  fixed  during  the  process  of  consolidation.  These  indications 
are  met  by  placing  the  limb  on  Lister's  splint  (Fig.  294),  which  consists 

Fig.  294. 


Hand  after  excisiun  ot  wii^t,  laid  in  spliiil 


of  an  obtuse-angled  piece  of  thick  cork  attached  to  a  splint,  with  a  cross- 
bar of  cork  attached  to  the  under  surface'  about  the  level  of  the  knuckles  ; 
on  the  splint  the  hand  lies  semi-flexed,  its  natural  ]iosition,  the  fingers 
midway  between  the  extremes  of  flexion  and  extension,  into  \\']iich  it  is 
necessary  to  bring  them  in  the  daily  passive  movements  ;  the  thumb  is 
to  be  kept  from  the  index  finger  by  a  pad  of  cotton  maintained  between 


RESECTION  OF  BONES. 


785 


behind 


Fig.  295. 


them ;  flexion  and  extension  of  tlie  fingers  slionld  be  commenced  on  the 
.second  day  whetlier  inflammation  has  subsided  or  not,  and  continued 
daily,  each  flnger  being  flexed  and  extended  to  the  fullest  degree  possible 
in  health,  care  being  taken  that  the  metacarpal  bone  concerned  is  held 
steady ;  pronation  and  supination  must  ni)t  be  neglected,  and,  as  the 
wrist  acquires  flrmness,  flexion  and  extension,  adduction  and  abduction, 
should  be  occasionally  encouraged ;  jJassive  motion  must  l)e  continued 
until  there  is  no  longer  a  tendency  to  contract  adhesions. 

The  radius  may  be  resected  for  necrosis  with  excellent  results,  the 
mortality  being  small  and  the  usefulness  of  the  hand  and  wrist  being 
well  preserved.  In  the  after-treatment  secure  rest  by  a  wire,  tin,  or 
sole-leather  splint  applied  to  the  inner  surface  of  the  arm  and  forearm, 
and  use  iodoform  dressings. 

(rt)  The  lower  extremity  is  broad,  of  a  quadrilateral  form,  ha\ing  two 
articular  surfaces,  one  concave,  on  the  lower  part,  for  articulation  with 
the  .scaphoid  and  semilunar  bones ;  the  other,  on  the  inner  side,  narrow 
and  concave,  to  articulate  with  the  lower  end  of  the  ulna.  Make  a 
longitudinal  int'ision  along  the  radius  on  its  external  anterior  border 
(Fig.  2!lo),  extending  downward  to  a  point  opposite  and  a  little 
the  styloid  process ;  if  necessary,  add  two 
terminal  incisions  at  the  extremities  of  the 
first  one  ;  remove  the  periosteum,  and  make 
section  of  Ijone  by  means  of  the  chain-saw  ; 
isolate  the  lower  part  of  the  radius  from  its 
attachments  at  the  radio-carpal  articulation, 
without  injury  to  the  artery  (a),  nerves,  or 
tendons. 

(b)  For  the  middle  portion  make  a  long 
straight  incision  on  the  external  aspect  of 
the  bone  parallel  with  its  shaft  ;  denude  the 
bone,  divide  it  at  the  two  points  selected, 
and  raise  the  fragment  from  its  bed,  leav- 
ing the  pcriosteimi. 

(c)  The  head  of  the  radius  is  quite  superficial  on  its  posterior  part 
and  surrounded  liy  tiie  orijicular  ligament,  which  reti.ius  it  in  the  lesser 
sigmoid  cavity  of  the  ulna.  Resect  by  making  a  straight  incision  on  the 
posterior  and  external  j)art  of  the  arm  over  the  bone,  divide  the  bone 
cautiously,  and  raise  it  from  its  articulation  by  cutting  the  ligaments 
with  the  point  of  the  knife. 

(r/)  In  excision  of  the  entire  radius  make  an  incision  along  the  outer 
surface  of  the  radius  from  the  styloid  process  t<i  the  head  of  the  bone  at 
the  elbow-joint;  divide  the  fascia  along  the  outer  border  of  the  supinator 
longus  muscle,  and  separate  the  muscles  along  this  line  down  to  the 
bone ;  incise  the  periosteum  the  length  of  the  wound  and  separate  it 
from  the  bone ;  divide  the  b(jne  in  the  middle  and  remove  each  extrem- 
ity separately. 

The  nhui,  like  the  radius,  may  be  resected  for  necrosis  with  very 
favorable  results,  i)oth  in  regard  to  mortality  and  usefulness  of  the  limb; 
l)nt  for  shot  injuries  the  mortality  is  in  the  aggregate  augmented  by  ope- 
rative interference,  except  \vhen  antiseptics  are  employed.  The  after- 
treatment  is  the  same  as  in  resections  of  the  radius. 

Vol.  I.— 50 


Resection  of  lower  end  of  radius. 


786  OPERATIVE  SURGERY. 

Romoval  of  the  lower  extreniitv  and  the  middle  ])ortion  of  the  shaft 
is  eft'eeted  by  the  same  metliods  as  those  <>i\-en  fcjr  the  radius. 

The  upper  extremity,  inehiding  the  olecranon,  is  exsected  as  follows : 
Make  a  longitudinal  incision,  live  inches  in  length,  over  the  middle  of 
the  olecranon,  extending  three  inches  above  and  two  below  it,  penetrat- 
ing to  the  bone  ;  divide  the  triceps  tendon  at  its  insertion  toward  either 
edge,  care  being  taken  to  avoid  cutting  across  the  aponeurosis,  whicli  is 
continuous  from  the  edges  of  the  tendon  over  the  muscles  lying  on  the 
posterior  part  of  the  forearm  and  inserted  into  the  edges  of  the  olecra- 
non ;  dissect  up  these  insertions  of  the  fascia,  as  well  as  the  origins  of 
the  muscles  beneath  it,  from  the  bone  to  the  extent  of  nearly  two  inches, 
which  allows  the  olecranon  to  be  exposed,  when  the  edges  of  the  incision 
may  be  drawn  asunder  over*  the  condyles,  broad,  curved  spatuliB  being 
used  for  this  purpose ;  with  the  amputating  saw  cut  through  one-half 
the  thickness  of  the  bone ;  comjjlete  the  section  \\\i\\  a  fine  saw,  after 
which  separate  com])letely  with  a  chisel  and  mallet. 

The  entire  ulna  may  be  removed  by  the  following  method  :  Rotate 
the  limb  inward  from  the  shoulder-joint,  and  carry  the  pronation  of  the 
forearm  so  tar  as  to  cause  the  jialm  of  the  hand  to  look  directly  outward  ; 
slightly  flex  the  elbow-joint  and  elevate  the  hand  ;  this  twisted  position 
places  the  ulna  ujjon  the  posterior  and  outer  asjject  of  the  forearm,  and 
renders  it  more  easily  accessible ;  the  limb  thus  placed,  the  assistants 
maintaining  the  arm  and  fiircarm  steadily,  make  an  incision  along  the 
jiosterior  and  inner  asjject  of  the  idna,  commencing  at  the  lower  part  of 
its  superior  third  and  extending  downward  to  a  point  over  the  extremity 
of  the  styloid  jtrocess,  make  a  transverse  incision,  about  an  inch  long, 
from  the  loAver  extremity  of  the  first  incision,  detach  the  tendon  of  the 
extensor  carpi  ulnaris  from  its  groove  on  the  lower  part  of  the  ulna, 
the  ulnar  artery  and  nerve  being  carefully  avoided  ;  divide  the  bone  at 
the  lower  part  of  the  middle  third,  and  separate  the  lower  and  upper 
fragments  from  their  articular  connections  as  in  the  removal  of  these 
bones  already  described. 

The  radius  a\n\.  ulna  may  be  I'emoved  together,  and  if  the  periosteum 
remains  a  useful  limb  may  result.  Make  a  straight  incision  the  entire 
length  of  each  bone  on  the  dorsal  surfaces,  separate  the  muscles,  and 
when  the  Ijone  is  reached  raise  the  periosteum  and  detach  the  articidar 
extremities ;  keep  the  limb  well  extended  during  the  after-treatment. 

The  elbow-joint  has  two  motions,  flexion  and  extension,  which  are 
limited  to  the  locking  of  the  coronoid  and  olecranon  processes  in  the 
respective  fossae  of  the  humerus.  The  usefulness  of  the  joint  after  excis- 
ion depends  upon  the  perfection  of  the  hinge-  or  antero-posterior  motion. 
The  extreme  conditions  in  which  it  may  be  left  are  ankylosis  and  a  flail- 
like or  dangle-joint  action.  Though  in  both  cases  the  limb  is  often  very 
useful,  yet  ever}^  effort  should  be  made  to  avoid  such  results.  After- 
treatment  has  much  to  do  with  the  prevention  of  ankylosis,  but,  in  gen- 
eral, the  extent  of  exsection  determines  the  degree  of  mobility,  and  also 
the  power  of  controlling  it ;  if  too  little  is  taken  away,  there  will  be 
more  or  less  comjilete  ankylosis,  and  if  too  much,  there  will  be  such 
relaxation  of  the  muscles  as  to  prevent  their  efficient  action  :  excisions 
which  have  given  the  best  results  have  been  at  the  commencement  of  the 
condyloid  projections  of  the  humerus  and  at  the  base  of  the  coronoid 


RESECTION  OF  BONES.  787 

process  of  tlie  ulna.  The  periosteum  should  be  carefully  j>rc.ser\-e(l, 
whatever  method  is  adojjted.  It  may  be  established  as  a  rule  that  excis- 
ion for  injury  shoidd  be  partial  and  conservative,  and  for  disease  it 
should  be  entire  or  limited  only  by  the  removal  of  the  diseased  boue. 
Wlien  the  disease  or  injury  is  limited,  it  is  of  doubtful  propriety  to  inflict 
additional  injury  by  section  of  healthy  bones,  for  excellent  results  have 
been  obtained  when  the  joint-ends  of  either  the  upper  or  forearm  have 
been  removed  after  complete  exposure  of  the  joint  and  the  uninjured 
portions  of  the  articulation  have  been  unmolested.  In  general,  the 
longitudinal  incision,  by  giving  sufficient  exposure  of  the  joint  and 
enabling  the  operator  to  avoid  easily  the  transverse  division  of  muscidar 
attachments,  ligaments,  and  fibrous  structures,  should  be  preferred.  The 
subperiosteal  method  gives  the  best  results  as  to  the  usefulness  of  the 
limb,  and  should  be  performed  unless  the  conditions  recpiire  the  sacrifice 
of  these  tissues.  Subperiosteal  exsection  is  as  follows  :  Make  an  incision, 
A  (Fig.  296),  three  inches  long  on  the  posterior  surface  of  the  joint,  a 
little  internal  to  the  middle  of  the  olecranon,  beginning  about  an  inch 
above  the  tip  of  the  olecranon,  and  extending  an  inch  and  a  half  or  two 
inches  above  that  jioint,  upon  the  border  of  the  ulna,  and  through  mus- 
cle, tendon,  and  periosteum  to  the  bone  ;  with  the  elevator  raise  the  peri- 
osteum of  the  ulna  toward  the  inner  side,  and  detach  the  inner  half  of 
the  tendon  of  the  triceps  in  connection  with  the  periosteum  by  means  of 
short,  parallel,  longitudinal  incisions;  with  the  left  tiiumb-nail  draw  the 
soft  parts  which  cover  the  internal  condyle  and  enclose  the  ulnar  nerve 
toward  the  epicondyle,  and  detach  them  by  means  of  curved  incisions 
until  the  epicondyle  is  entirely  uncovered  ;  the  last  incisions  separate  the 
origins  of  the  flexor  muscles  and  the  internal  lateral  ligament,  their  con- 
nections with  the  jjeriosteum  being  retained  ;  noAV  draw  the  outer  portion 
of  the  triceps  tendon  outward  and  separate  it  by  short  incisions  from  the 
olecranon,  maintaining,  however,  its  connections  with  the  ]>eriosteum  of 
the  outer  side  of  the  ulna,  which  is  raised  from  the  bone  with  the  inser- 
tions of  the  anc(incus ;  by  repeated  incisions  along  the  bone  loosen  the 
fibrous  capsule  of  the  joint  from  the  margin  of  the  humerus,  first  over 
the  trochlea,  until  the  internal  condyle  appears  ;  detach  the  external  lat- 
eral ligament  and  origins  of  tlie  extensor  muscles,  so  that  all  remain  in 
connection  with  each  otlier  and  the  periosteum ;  now  forcibly  flex  the 
arm,  ])rotrude  the  articular  surfaces  through  the  wound,  and  saw  them 
off;  if  the  idna  is  sawn  off  l)elow  the  coronoid  process,  separate  the 
upper  fasciculi  of  the  brachialis  anticus  without  disturbing  the  union  t)f 
the  tendon  with  the  periosteum.  Subperiosteal  resection  may  be  so  pei- 
formed  as  to  retain  the  origins  of  muscles  as  follows :  Make  parallel 
incisions  of  proper  length  over  the  external  and  internal  condyles  ;  raise 
the  soft  parts  from  the  internal  condyle,  separate  the  attachments  of  the 
flexors  with  lamelhq  of  Ijone  by  means  of  a  chisel ;  raise  the  peri- 
osteum on  both  surfaces  with  the  elevator,  and  divide  the  lateral  liga- 
ment ;  repeat  the  same  operation  on  the  external  condyle ;  now  divide 
the  humerus  above  the  condyles ;  scjiarate  the  attachments  of  the  triceps 
with  the  periosteum  and  laniellaj  of  bone  ;  detach  the  coronoid  jjrocess 
from  the  ulna ;  divide  the  extremity  of  the  ulna  and  remove  it. 

Other  incisions  mav  be  made  as  follows:  Fig.  296,  B,  Oilier;  Fig. 
297,  A,  Nelaton,  B,  C,  Hiiter. 


788 


OPERATIVE  SURGERY. 


An  osteoplastic  operation  may  be  jicrloinicd  as  follows  (^1,  Fig.  298)  : 
Make  an  incision  from  the  end  of  the  external  condyle  across  the  olecra- 


FiG.  296. 


Mt'thorls  of  Van  Lan- 
genbeck  and  Oilier. 


Fig.  297 


^ 


11 


■B 


r-A 


Methods  of  Nflatou  and 
Huter. 


Fig.  298. 


'.   B 


\    I 

Osteoplastic  method  :  A, 
Von  Mosetig-lloorhof; 
B,  by  external  incision. 


non,  then  upward  alono;  the  olecranon  to  a  point  an  inch  above  its  end  ; 
draw  aside  the  ulnar  nerve  and  divide  the  olecranon  ;  now  expo.se  the 
hiunerus  and  saw  it  oif  below  the  epicondyles ;  remove  the  head  of  the 
radius  and  reunite  the  olecranon  with  wire.  An  external  incision,  B, 
can  be  adopted. 

The  humerus  is  generally  resected  in  part,  though  it  has  been  re- 

FiG.  299. 


Resection  of  lower  end  of  humerus. 


moved  entire,     (n)  The  lower  extremity  of  the  humerus  is  resected  as 
follows  :  ISIake  a  straight  incision  on  tiie  posterior  and  external  part  of 


RESECTION  OF  BONES. 


789 


the  arm  (Fig.  299)  sufficiently  extensive  to  give  a  free  exposure  of  the 
boue,  u,  when  the  wound  is  separated  ;  denude  the  bone  and  divide  with 
the  chain  saw ;  raise  the  cut  end,  and  ])roceed  to  disarticulate  with  the 
point  of  the  knife,  carefully  avoiding  the  brachial  artery  in  fi-ont  and 
the  ulnar  nerve  behind  and  at  the  inside. 

(6)  Resection  of  the  shaft  requires  the  utmost  care  to  avoid  wounding 
the  brachial  artery,  which,  with  the  median  and  ulnar  nerves,  passes 
along  the  posterior  margin  of  the  biceps  nuiscle,  and  the  superior  pro- 
funda arterv  and  museido-spiral  nerve,  which  wind  around  the  posterior 
and  external  jiart  of  the  upper  and  middle  portions  of  the  shaft.  If  the 
u])]K'r  portion  of  the  shaft  is  to  be  removed,  make  a  straight  incision  on 
the  external  part  of  the  deltoid  muscle,  care  being  taken  not  to  extend 
the  incision  upw'ard  so  as  to  involve  the  circumflex  artery  and  nerve  ; 
when  the  lower  part  of  the  shaft  is  excised,  the  incision  should  be  along 
the  outer  border  of  the  braehialis  anticus  muscle,  avoiding  the  musculo- 
spiral  and  external  cutaneous  nerves ;  the  bone  is  readily  exposed  and 
removed  to  the  required  extent. 

(c)  The  upper  extremity  consists  of  the  head  surrounded  by  the  cap- 
sular ligament,  the  tuberosities,  and  shaft.  Resect  thus  :  Make  a  straight 
incision,  commencing  a  little  above  and  outside  of  tlie  coracoid  process 
and  half  an  inch  below  the  clavicle,  and  carry  it  downward  to  the 
requisite  extent  along  the  deltoid  muscle  on  the  anterior  part  of  the 
joint ;  the  bone  is  here  quite  superficial,  and  is  most  readily  exposed ; 
the  bicipital  groove  being  found,  dislodge  the  long  head  of  the  bicejjs 
muscle  and  draw  it  aside  (Fig.  300,  b) ;  divide  the  tendons  of  the  sub- 

FiG.  300. 


Resection  of  upper  end  of  humerus. 

seapularis,  supra-  and  infra-spinatus,  and  teres  minor  as  they  are  made 
tense  by  rotation  of'  the  bone  outward  and  inward  ;  open  the  capsule 
and  resect. 

{(I)  The  entire  humerus  may  be  extirpated  :  tlie  thickened  periosteum 
must  be  left  in  the  wountl,  and  the  lengtli  of  the  limb  j^rescrved  in  order 
to  aid  the  formation  of  new  bone,  on  which  the  usefulness  of  the  extremity 
will  depend.  If  no  new  bone  forms,  the  patient  may  have  a  useful  arm 
suppoi-ted  by  a  ball-and-socket  aj>paratus  from  the  shoulder.     The  in- 


790 


OPERATIVE  SURGERY. 


Fig.  301. 


cision  must  be  the  same  as  for  the  resection  of  the  upper  and  lower  ex- 
tremities, avoiding  carefully  the  musculo-spiral  nerve. 

The  nhouldcr-Joiiif  consists  of  the  large  and  hemispherical  head  of 
the  humerus,  opjtosed  to  the  nnich  smaller  surface  of  the  glen()i<l  eavity 
of  tlie  scapula;  the  ligaments  are  the  capsular,  which  invests  the  joint; 
the  coraco-humeral,  a  broad  bundle  of  iibres  extending  over  the  upper 
and  outer  part  and  attached  to  the  root  of  the  coracoid  process ;  and  the 
glenoid,  which  surrounds  and  deepens  the  articulation.  The  method  of 
operation  has  a  marked  relation  to  the  usefuhiess  of  the  limb  ;  e.  (j.  the 
longitudinal  incision  gives  <S  per  cent,  perfect  and  45.6  per  cent,  useful 
limbs;  the  various  other  incisions  give  but  a  fracticin  over  1  per  cent, 
perfect,  and  at  the  highest  1 1  per  cent,  useful  limbs.  The  straight  in- 
cision should,  therefore,  be  preferred  in  oi'dinary  excisions.  iSubperios- 
teal  excision  of  the  humerus  should,  as  far  as  possible,  be  practised  in 
order  to  secure  greater  length  of  limb,  for  while  the  degree  of  shortening 
ordinarily  bears  a  certain  relation  to  the  extent  of  bone  excised,  in  sub- 
jx'riosteal  exsections  this  law  docs  not  hold  good,  the  shortening  l)eing 
comparatively  vastly  less  in  the  latter  ;  c.  g.  3.93  inches  removed  with 
periosteum  gave  3  inches  shortening,  while  4  inches  removed  subperios- 
teal gave  only  ^  an  inch  shortening. 

Exsection  may  be  periornied  l)v  the  methods  alrendv  given  (Fig. 
300),  or  as  follows  :  The  patient  lying  on  the  back,  the  shoulder  raised 
on  a  cushion,  and  the  external  condyle  looking  forward,  make  an  in- 
cision, A  (Fig.  301),  from  the  acromion 
directly  downward  through  the  deltoid 
muscle  to  the  capsule  and  periosteum  ; 
draw  aside  the  margins  of  the  wound 
with  retractors  and  recognize  the  tendon 
of  the  long  head  of  the  biceps ;  run  the 
point  of  the  knife  along  the  outside  of 
the  tendon,  ojjening  the  groove  and  cap- 
sule to  the  acromion  ;  draw  the  tend(in 
to  one  side,  and,  while  the  arm  is  rotated 
outward,  with  a  circular  sweep  of  the 
knife,  held  perpendicularly  to  the  bone, 
divide  the  ca2:)sule  and  the  attachment 
of  the  subscapularis  to  the  lesser  tuber- 
osity ;  then  rotate  the  arm  inward,  and 
in  the  same  manner  sever  the  capsule 
and  the  insertions  of  the  supra-  and  infra-spinatus  and  teres  minor  from 
the  greater  tuberosity  :  the  head  of  the  bone  is  now  thrust  out  of  the 
wound  and  removed  by  a  narrow  back  saw  passed  behind  it.  Any  por- 
tion of  the  glenoid  cavity  may  be  exsected  through  this  wound.  If 
larger  space  is  required,  an  additional  incision  may  be  such  as  to  com- 
pletely expose  the  joint  and  parts  adjacent,  B  (Fig.  301).  Subjicriostcal 
resection  may  be  eft'ccted  by  this  method  as  follows :  Di\ide  the  pei'i- 
osteum  along  the  incision  and  raise  it  from  the  bone,  first  on  the  inside 
while  the  arm  is  rotated  outward,  detaching  with  it  the  insertions  of  the 
subscapularis ;  then  on  the  outside  while  the  arm  is  rotated  inward,  sep- 
arating the  insertions  of  the  external  rotators  ;  this  pai't  of  the  operation 
is  difficult  in  jjrimary  resection  owing  to  the  thinness  of  the  periosteum ; 


Excision  of  the  shoulder:  A,  regular  In^ 
cisiou ;  B^  supplementary. 


RESECTION  OF  BONES. 


791 


the  head  of  the  bone  being  now  exposed,  it  may  be  turned  out  and  ex- 
cised. 

The  treatment  consists  in  fixing;  tiie  arm  upon  the  triangular  cushion, 
and  applying  iodoform  dressings  and  inserting  a  suitable  drainage-tube  ; 
in  ])riinai'y  exsection  the  tube  may  pass  out  of  an  opening  made  poste- 
ri(_)rly,  the  wound  itself  being  iirmly  closed  l)y  sutures. 

The  scapula,  in  part  or  in  whole,  has  been  resected  for  shot  injuries, 
necrosis,  and  morbid  growths.  For  shot  injuries  it  is  sometimes  neces- 
sary to  excise  undetached  portions  of  bone  to  facilitate  the  extraction  of 
foreign  bodies,  and  when  there  is  great  comminution  it  may  be  advisable 
to  excise  considerable  portions  of  bone ;  there  may  be  conditious  also 
resulting  from  lacerations  by  large  projectiles  which  would  render  jiriniary 
extirpation  of  the  scapula  advisable ;  but,  as  a  rule,  it  is  better,  after 
removing  detached  fragments,  to  wait  the  efforts  of  nature  to  consolidate 
the  fractured  bone,  and  to  resort  to  resection  as  an  intermediary  or 
secondary  measure  in  cases  of  extended  necrosis.  Extirpations  of  the 
entire  scapula  for  morbid  growths  have  proved  so  successful  as  to  render 
it  a  legitimate  operation. 

(a)  Till'  body  may  be  removed  to  a  greater  or  less  extent,  as  follows  : 
Make  three  incisions,  one  along  the  spine  and  the  other  two  from  its 
extremity,  one  upward  and  the  other  downward  ;  dissect  flaps  from  the 
supra-  and  infra-spinatus  fossae,  saw  through  the  root  of  the  acromion,  and 
denude  the  anterior  and  posterior  surfaces  of  the  bone ;  reverse  the  body 
of  the  scapula  from  within  outward,  and  divide  the  part  at  the  ])ro])er 
point  witli  the  saw.  Or  make  a  longitudinal  incision  extending  from  tlie 
superior  to  the  intiM-ior  angle  along  the  vertebral  border,  a  second  parallel 
incision  extending  from  the  neck  of  the  acromion  to  the  middle  of  the 
anterior  border ;  a  transverse  incision 
unites  these  along  the  spine  ;  dissect 
the  flaps,  detach  the  muscles  poste- 
riorly and  anteriorly,  and  divide  the 
bone  with  the  ciiain  saw  or  forceps. 

(6)  The  s])ine  may  bo  resected  by 
an  incision  made  parallel  to  its  bor- 
der ;  if  required,  the  incision  may  be 
curved  downward,  so  as  to  raise  a 
flap  ;  tlie  l)one  being  denuded,  the  dis- 
eased portions  may  be  removed  with 
a  strong  cutting  forceps.  To  resect 
the  acromion  make  a  semihuiar  inci- 
sion at  the  posterior  part  of  the  shoul- 
der with  the  convexity  downward ; 
pass  the  chain  saw  under  the  nar- 
row part  of  the  neck  of  the  acro- 
mion, divide  the  bone  at  this  part, 
and  disarticulate  ;  or  make  a  crucial 
or  T-ineision.  An  angle  of  the  scap- 
ula may  be  resected  by  a  transverse,  or 
a  V,  or  a  crucial  incisi<m  over  the  part. 

((•)  C'halot  descril)es  a  suljspino-glenoid  and  a  retro-coraco-glenoid  ex- 
cision by  the  lines  of  incision  shown  in  Fig.  302. 


Fig.  302. 


aft,  subspino-glenoid  excision :  ac,  retro-coraco- 
glenoid  excision  (Chalet). 


792 


OPERATIVE  SURGERY. 


{iJ)  Tlic  entire  scapula  is  reinoved  hy  an  iiicisidii  from  tlie  acromion 
process  to  tiie  posterior  etlj^o  of  the  scapula,  and  another  from  the  centre 
of  this  one  downward ;  reflect  the  flaps  thus  formed,  separate  the  scap- 
ular attaclinient  of  the  deltoid,  and  divide  the  connections  of  the  acro- 
mial extremity  of  the  clavicle ;  to  command  the  subscapular  artery 
divide  and  tie  it  without  delay ;  next  cut  into  the  joint  and  around  the 
glenoid  cavity,  hook  the  finger  under  the  coracoid  process,  so  as  to  foeil- 
itate  the  division  of  its  muscular  and  ligamentous  attacinnents ;  then, 
pulling  back  the  l)one  foreil)ly  with  the  left  hand,  separate  its  remaining 
attachments  with  rapid  sweeps  of  the  knife. 

The  clavicle  has  such  immediate  relations  to  the  upper  walls  of  the 
thoracic  cavity  that  operations  for  its  extirpation  must  be  cautiously  per- 
formed. In  shot  fractures,  detached  splinters  sliould  always  be  imme- 
diately extracted  ;  necrosed  bone  should  be  cautiously  removed,  in  order 
not  to  injure  neighboring  parts;  tlie  removal  of  morbid  growths  in- 
volving the  clavicle  may  prove  to  be  a  most  serious  operation. 

(a)  The  scapular  extremity  is  broad  and  flat,  and  is  removed  by  a 
curved  incision  with  its  convexity  forward  and  a  little  outward,  which, 
reflected  backward,  completely  exposes  the  bone.  For  a  tumor  make  a 
crucial  incision  through  the  integuments  and  the  platysma  myoides,  one 
limb  nearly  in  a  line  with  the  clavicle  and  the  otlier  at  right  angles,  and 
dissect  the  flaps  and  fascial  coverings  suecessi^■ely  down  to  the  external 
basis  of  the  tumor ;  carefully  detach  the  pectoralis  and  deltoid  muscles 
from  their  clavicular  origin,  avoiding  the  cephalic  vein,  and  divide  on  a 
director  the  fibres  of  the  trapezius  and  the  cleido-mastoid  muscles.     Dis- 


FiG.  303. 


a  b,  resection  of  diaphysis  of  clavicle ;  cde  f  g k,  resection  of  entire  clavicle 
i  jy  total  resection  of  cartilage  of  rib. 


articulate  the  scapular  extremity  of  the  bone,  and  the  mobility  thus  com- 
municated to  the  mass  facilitates  the  completion  of  the  operation. 

(b)  The  entire  clavicle  may  be  resected  by  an  incision  ]iarallel  to  its 
inferior  border  extending  to  or  a  little  beyond  its  extremities ;  add  t\\o 


RESECTIOy  OF  BONES. 


793 


Frci.  304. 


vertical  incisions,  of  one  to  two  inches  in  length,  at  the  ends  of  the  first 
incision  ;  the  flap  resulting  from  which  divisions,  on  being  raised  up, 
completely  lays  bare  the  bone  (Fig.  303).  For  a  tumor  make  an  incision 
from  the  acromial  extremity  of  the  clavicle  to  the  sternal  extremity  of  the 
clavicle  of  the  <)p])()site  side  ;  cross  this  by  an  incision  at  right  angles  with 
it  in  the  middle  of  the  clavicle  ;  dissect  the  four  flajis  from  the  surface  of 
the  tumor;  detach  the  deltoid  from  its  anterior  and  tlie  trapezius  from  its 
posterior  edge,  and  divide  the  coraeo-clavicular  ligament ;  pass  the  chain 
.saw  and  divide  the  bone  ;  seize  the  fragment  with  the  forceps,  and  detach 
the  soft  parts  with  the  point  of  the  knife,  the  edge  being  kept  constantly 
turned  toward  the  bone,  in  order  not  to  make  the  slightest  wound  of  the 
.soft  parts. 

((•)  The  sternal  extremity  is  of  a  triangular  form,  and  has  on  its  postero- 
superior  surface  the  sterno-mastoid  and 
sterno-hyoid  muscles,  on  its  anterior  sur- 
face the  pectoralis  major  muscle  ;  poste- 
riorly it  is  in  near  relation  with  the 
pleura,  internal  mammary  artery,  sub- 
clavian vein,  and  transverse  cervical 
artery  ;  the  innominata  is  on  the  right 
and  the  thoi"acic  duct  on  the  left  side. 
Resect  as  follows  :  Make  (Fig.  304)  an 
incision  curved  downwai'd,  the  degree  of 
the  curvature  depending  upon  the  size 
of  the  bone,  but  ah\'ays  so  arranged  as 
to  enable  the  operator  to  raise  it  by  dis- 
section to  the  upper  part ;  after  raising 
the  flap,  instead  of  separating  the  mus- 
cles, pass  a  chain  saw  at  the  point  where 
the  bone  is  to  be  divided ;  remove  the 
fragment  l)y  carefully  disarticulating  it  with  the  point  of  the  knife,  and 
avoid  wounding  the  important  parts  posteriorly. 


Rescctiou  of  sternal  end  of  clavicle. 


Fig.  305. 


BONES    AND    JOINTS    OF   THE    LOWER    EXTREMITIES. 

The  lower  limbs  are  employed  in  support  and  progression,  and  hence 
resections  should  be  so  performed  as  to  preserve  the  utmost  stability. 

Tiie  plKtlangcs  of  the  toes  and  their  joints  may  be  resected  by  the 
nietliods  given  for  the  corresponding  bones  of  the  fingers.  The  great 
toe  is  of  the  utmost  value  in  progression,  and  in  removing  diseased  bone 
from  any  ])art  of  it  every  effort  must  be  made 
to  ritaiu  periosteum,  with  a  view  to  the  pre- 
.servation  of  its  function. 

The  metntarml  bones,  like  the  metacarpal, 
may  be  partially  or  entirely  removed,  and  by 
similar  methods.  The  resection  of  the  entire 
first  and  fifth  metatarsal  bones  requiresacurved 
incision  witli  its  convexity  downward,  a,  h,  <■ 
(Fig.  305),  and  extending  beyond  tlie  articu- 
lation ;  the  bone  Ijeing  exposed,  the  middle  of  the  shaft  should  be  divided 
with  the  saw  and  the  fragments  separately  disarticulated.     In  the  removal 


Resection  of  metatarsal  bone. 


794 


OPERA  TI T  'E  S  VR  GER  Y. 


Fig.  306. 


of  the  three  middle  metatarsal  bones  a  long  straight  incision  should  be 
made,  the  bone  divided  in  its  centre,  and  the  operation  (completed  as  in 
the  preceding  case. 

The  metatarso-tarsal  joiiit><  are  exsccted  by  a  semilunar  incision  on 
the  dorsum  of  the  foot,  exposing  the  first  row  of  tarsal  bones.     Remove 

their  surfaces  with  a  saw ;  now  expose  the 
arti(!ular  surfaces  of  the  metacarjjal  bones 
and  excise  them. 

Tlie  Utrxdl  hones  vciay  require  removal 
singly  or  in  groups.  These  operations 
have  never  been  performed  according  to 
any  prescribed  rules,  but  each  operator 
lias  adapted  his  incisions  to  the  exigencies 
of  the  individual  operation.  In  many  cases 
the  hones  iiave  not  been  resected  entire, 
but  the  portion  of  bone  diseased  has  been 
removed  with  a  gouge.  Care  should  be 
taken  not  to  involve  the  synovial  mem- 
brane of  adjacent  articulations  which  do 
not  conmiunicate  with  the  point  involved 
(Fig.  3()(i),  and,  whenever  practicable  the 
periosteum  should  be  preserved.  The  as- 
tragalus and  OS  calcis  require  special  notice. 
The  astragalus  has  most  important  con- 
nections :  above  it  articulates  with  the  tibia, 
laterally  with  the  malleoli,  and  t)elow  with 
the  ealcaneum  by  two  surfaces.  It  is  attaciied 
to  the  ealcaneum  by  the  interosseous,  pos- 
terior, and  external  ligaments,  and  to  the  scaphoid  by  a  ligament  passing 
from  its  anterior  extremity.  Excision  may  be  made  with  slight  injury 
to  the  tendons  which  pass  over  that  region  or  by  their  destruction.    The 


a,b. 


,  d,  e,  distribution  of  synovial 
membranes. 


Fig.  307. 


A.  excision  of  astragalus  (inner  incision) ;  A,  excision  of  ankle  (inner  incision). 


former  methods  are  very  tedious,  but  give  the  best  results.  Excision  is 
as  follows  :  Make  an  external  incision  two  and  a  half  inches  in  length, 
A  (Fig.  308),  from  the  lower  extremity  of  the  tibia  and  anterior  to  the 


RESECTION  OF  BONES. 


r95 


external  malleolus,  to   the   middle   of  the  cuboid  bone,  and  a  second 
incision  backward  from  the  centre  of  this  incision  just  under  the  mal- 


FiG.  308. 


A,  excision  of  astragalus  (outer  incision) ;  B,  excision  of  ankle  (outer  incision) ;  C,  excision  of 

OS  calcis. 


Fig.  309. 


leolus  ;  the  bone  is  thus  exposed  between  the  peroneus  brevis  and  tertius  ; 

all  its  connections  should  be  divided.     ISIake  an 

internal  incision  two  inches  long,  A  (Fig.  308), 

from  just  below  the  tip  of  the  inner  malleolus,  in 

a  curved  direction,  along  its  anterior  margin, 

forward  and  upward  ;    separate  all   ligaments ; 

seize  the  bone  with  strong  forceps  and  withdraw 

it,  dividing  any  remaining  attachments. 

The  OS  calcis  articulates  above  with  the  astrag- 
alus by  two  articular  sm-faces  having  an  inter- 
osseous ligament ;  in  front  with  the  cuboid,  to 
which  it  is  firmly  bound  by  four  ligaments,  two 
plantar,  which  are  very  strong,  a  dorsal  and  an 
interosseous.  Kesection  by  the  plantar  flap  (Fig. 
309)  gives  ready  access  to  the  bone  and  removes 
the  cicatrix  from  the  plantar  surface.  The 
patient  lying  upon  his  face,  make  a  horseshoe 
incision ;  carry  it  from  a  little  in  front  of  the 
calcaneo-cuboid  articulation  around  the  heel, 
along  tiie  sides  of  the  foot  to  a  corresponding 
point  on  the  opposite  side  ;  dissect  up  the  elliptic 
flap  thus  formed,  the  knife  being  carried  close  to 
the  bone,  and  thus  expose  the  whole  under  sur- 
face of  the  OS  calcis ;  then  make  a  perpendicular 
incision  about  two  inches  in  length  behind  tiie 
heel  tlu'ough  the  tendr>  Achillis,  in  the  middle 
line  and  into  the  horizontal  one ;  detach  the 
tendon  from  its  insertion  and  dissect  up  the  two 
lateral  flaps,  the  knife  being  kept  close  to  the 
bones,  from  which  the  soft  parts  are  well  cleared  ; 
then  carry  the  blade  over  the  upper  and  posterior  pai*t  of  the  os  calcis, 


Excision  of  the  os  calcis. 


796  OPERATIVE  SURGERY. 

open  the  articulation,  divide  the  interosseous  ligaments,  and  then  by  a  few- 
touches  with  (lie  ]ioint  det;ieli  the  Ixine  from  its  coinieetions  with  tiie 
cuboid.  Faral)euf  has  modified  this  metiiod,  ('  (Fig.  •"JOT,  Treves),  by 
making  an  incision  from  the  base  of  the  fifth  metatarsal  bone  along  the 
margin  of  the  sole  to  a  point  one  and  a  quarter  inches  to  the  inner  side 
of  the  median  line  ;  another  incision,  two  inches  long,  parallel  to  and  a 
little  in  front  of  the  tendo  Achillis,  joins  the  first.  The  flaps  are  raised 
from  the  bone,  the  periosteum  cut  vertically  and  raised  from  the  bone, 
<'are  being  tiiken  not  to  injure  the  j)eronei  tendons  in  front.  By  careful 
dissection  the  bone  is  freed  from  its  attachment  and  removed. 

The  tarsal  joints  generally  become  carious  in  connection  with  such 
extensive  caries  of  the  tarsal  bones  as  necessitates  the  extirpation  of 
entire  bones.  Single  joints  may  be  excised  when  the  disease  is  limited, 
as  the  astragalo-seaphoid,  a  (Fig.  oOG),  the  calcaneo-scaphoid,  the  cal- 
caneo-cuboid,  h.  The  incision  should  be  made  over  the  aflected  joint 
and  curved,  and  the  articular  surfaces  should  be  removed  with  a  fine  saw 
or  gouge. 

The  ankle-joint  is  a  hinge ;  the  inferior  extremities  of  the  tibia  and 
fibula  united  form  a  kind  of  arch  which  embraces  transversely  the 
superior  articular  surface  of  the  astragalus  so  as  to  render  lateral  move- 
ments impossil)le  when  the  ligaments  are  tense. 

The  operation  which  best  preserves  vessels,  nerves,  and  tendons,  as 
well  as  the  periosteum,  is  by  two  longitudinal  incisions,  one  over  the 
external  and  the  other  over  the  internal  malleolus,  and  extended  above 
and  l)clow  sufficiently  to  give  free  access  to  all  of  the  diseased  bone. 
All  transverse  incisions  involving  tlic  vessels,  nerves,  and  tendons  should 
be  avoided.  The  limb  being  turned  on  the  inner  side  upon  a  firm  pil- 
low, make  an  incision  two  or  three  inches  long  i^  (Fig.  307)  on  the  mid- 
dle of  the  fibula  down  to  the  point  of  the  malleolus,  and  sufficiently  deep 
to  divide  the  periosteum  ;  from  the  extremity  of  the  malleolus  continue 
the  incision  backward,  around  the  malleolus,  an  inch,  merely  through 
tlie  skin,  so  as  not  to  injure  the  tendons,  and  yet  permit  of  their  being 
raised  from  behind  the  malleolus  ;  at  the  point  where  the  bone  is  to  be 
divided  separate  the  periosteum  with  the  raspatorium,  and  turn  down  as 
much  as  circumstances  will  permit ;  introduce  the  point  of  the  index 
finger  or  a  spatula  into  the  interosseous  space  to  protect  the  soft  parts 
during  the  act  of  sawing ;  incline  the  saw  slightly  toward  the  joint,  so 
that  the  part  to  be  removed  will  be  external  at  the  point  of  division  ; 
seizing  the  upper  extremity  of  the  fragment  with  very  strong  forceps, 
separate  its  connections  with  the  raspatorium  and  knife  when  necessary. 
Now  turn  the  foot  upon  the  external  surface,  and  make  the  same  straight 
incision  as  upon  the  fibula,  and  a  transverse  one  at  its  lower  end,  B  (Fig. 
308);  the  periosteum  is  more  easily  separated  than  from  the  fibula  ;  saw 
the  til)ia  in  j)lace  with  a  fine-bladed  saw  when  the  parts  are  unyielding 
from  chronic  inflammatory  infiltration  ;  in  recent  injuries  and  acute  sup- 
jiurations  it  may  be  j)ossible,  after  the  jjcriosteum  has  been  separated 
and  the  ligaments  incised,  to  gradually  dislocate  the  foot  outward  with 
the  aid  of  the  knife,  and  remove  tlic  tibia  with  the  saw.  To  gain  more 
complete  access  in  many  cases  the  incisions  made  along  the  centre  of  the 
malleoli  may  be  extended  laterally  along  the  margins  of  the  extremities 
of  these  bones.     Or  the  same  result  may  be  attained  by  extending  the 


RESECTION  OF  BONES. 


r97 


Fig.  310. 


incisions  made  along  the  posterior  margins  of  the  tibia  and  fibnla  around 
the  kiwer  and  anterior  margins  of  tlie  niaUeoli. 

A  convenient  method  of  suspending  the  limb  is  as  follows  :  Make  a 
splint  of  wood  or  metal  fitted  to  the  anterior 
surface  of  the  leg  and  ankle  (Fig.  310),  with 
rings  inserted  at  three  points  for  suspension ; 
in  its  application  the  splint  is  well  padded 
and  laid  on  tlie  front  part  of  the  leg  and  tiie 
limb  fixed  in  the  ordinary  bandage,  the  ankle 
being  free  (Fig.  311);  or  the  gypsum  band- 
age may  be  applied  over  the  splint  and  around  the  leg,  a  layer  of  old 
flannel  being  first  adapted  to  the  leg,  and  the  ankle  left  exposed. 

Fig.  311. 


1 


Suspension  splint. 


Leg  suspended. 


Osteoplastic  excision  of  the  ankle-joint  (Mikulicz)  (Fig.  312,  ^1),  is  as 
follows :  Place  the  patient  in  a  prone  position,  and  make  the  following 
incision.s  down  to  the  bone :  1st,  across  the  sole  of  the  foot  from  a 
point  a  little  in  front  of  the  tubercle  of  tiie  scaphoid  to  a  point  just 
l)chind  the  tuberosity  of  tlie  fifth  metatarsal  bone;  2d,  from  the  extrem- 
ities of  this  incision  two  incisions  to  the  base  of  each  malleolus;  3d,  a 
transverse  cut  joining  tlie  ends  of  these  incisions,  a  ;  4th,  then  flex  the  foot, 
divide  the  lateral  ligaments,  and  open  the  joint  from  behind,  separate 
the  OS  calcis  and  astragalus  from  their  attachments,  and  remove  them  at 
the  medio-tarsal  articulations.  Remove  with  the  saw  the  extremities  of 
the  bones  of  the  leg  at  the  base  of  the  malleoli,  A,  and  the  articular  sur- 
faces of  the  scaphoid  and  cuboid.  Attacli  tlie  incised  bones  of  the  tarsus 
to  the  cut  surface  of  the  tibia  by  wire,  and  apply  the  usual  antiseptic 
dressings  supported  externally  by  gypsum  bandages.  The  result  is  a 
talipes  equinus  (Fig.  312,  E). 

The  fibula  may  be  resected  in  whole  or  in  part  with  the  best  results. 
No  formal  method  is  to  be  pursued.  Make  a  straight  incision  over  the 
part,  uncover  the  boiic,  separate  the  periosteum,  divide  with  a  chain 
saw,  and  remove  the  fragments  (Fig.  313). 

Th(!  tibia  is  subjected  to  resection  more  frequently  than  any  other 
long  lione,  owing  to  its  subcutaneous  situation.  The  results  are  most 
favorable,  as  new  bone  is  readily  reproduced  when  the  periosteum  is 
well  preserved. 

{a)  The  lower  extremity  forms  tiic  uj)per  and  internal  part  of  the 


798 


OPERA riVE  SURGERY. 
Fia.  312. 


Osteoplastic  excision  of  the  foot. 


ankle-joint ;  it  is  closely  invested  with  tendons,  and  upon  its  postero- 
internal border  the  posterior  tibial  artery  and  nerve  pass  to  the  foot. 


Fig.  313. 


Resection  of  fibula. 


RESECTION  OF  BONES.  799 

Resection  by  the  subperiosteal  method  of  the  entire  diaphysis  and  lower 
epiphysis  has  resulted  in  reproduction  of  the  bone  removed  and  a  useful 
limb."  Make  a  straight  incision  along  the  crest  to  the  ankle-joint;  saw 
the  bone  at  the  requisite  height ;  raise  the  bone  from  its  periosteal  bed 
by  carefully  separating  the  periosteum  ;  dislodge  the  tendons  from  their 
grooves,  divide  the  ligamentous  structures,  and  complete  the  resection  by 
tletaching  the  bone  from  the  articulation. 

(f))  The  shaft  of  the  tibia  is  subcutaneous  on  the  anterior  and  inner 
part.  On  the  posterior  part  it  gives  attachuicnt  to  muscles,  and  along 
its  external  border  is  attached  the  interosseous  ligament  connecting  it  to 
the  fibula.  The  operation  will  depend  upon  the  extent  of  the  disease 
and  the  location  of  the  sinuses  if  the  disease  is  necrosis.  The  incision 
should  be  ah^ng  the  subcutaneous  borders  of  the  bone,  and  extend  beyond 
the  diseased  portion  ;  the  periosteum  should  l)e  thoroughly  separated 
from  the  shaft,  and  the  bone  divided  with  a  chain-saw  at  either  extrem- 
ity ;  the  fragment  is  then  easily  separated. 

(c)  The  upper  extremity  of  the  tibia  is  broad,  and  presents  upon  its 
ujiper  surface  two  cup-shaped  cavities  for  articulation  \vith  the  condyles 
of  the  femur.  The  operative  process  is  entirely  subordinated  to  the 
degree,  actual  situation,  and  form  of  the  disease,  so  that  there  may  be 
occasion  for  the  crucial,  the  elliptical,  or  a  simple  incision,  and  also  for 
a  variety  of  saws  and  bone-cutting  instruments.  When  practicable,  sub- 
periosteal resection  should  always  be  performed. 

The  knee-joint  mav  be  regarded  as  consisting  of  three  articulations 
conjoined — namely,  that  between  the  patella  and  femur,  and  two  others,  one 
between  each  condyle  of  the  feiuurand  the  tibia  :  the  ligamentura  muco- 
sum  is  an  indication  of  the  original  distinctness  of  the  synovial  mem- 
branes of  the  inner  and  outer  joint ;  the  crucial  ligaments  may  be  re- 
garded as  the  external  and  internal  lateral  ligaments  of  those  two  joints 
respectively  ;  each  portion  of  the  articular  surface  of  the  femur  belongs 
either  to  one  or  other  of  the  three  component  joints  of  the  knee,  and  no 
part  is  common  to  any  two  of  them.  The  knee  is  a  hinge-joint,  having 
free  motion  in  but  two  directions ;  it  is  sui)ported  principally  by  the 
lateral,  the  internal,  and  the  posterior  ligaments,  and  in  front  by  the 
jiatella  and  its  ligamentous  attachments  ;  it  has  also  a  capsular  ligament ; 
the  articular  face  of  the  tibia  has  a  semilunar  fibro-cartilage  which  deepens 
the  articular  surface  for  the  condyles  of  the  fcnuir. 

Present  experience  indicates  that  excision  should  be  had  recourse  to 
M'henever  the  injury  or  disease  is  of  a  nature  to  destroy  the  function  of 
the  joint  and  to  require  ankylosis  to  render  the  limb  useful.  It  is  gene- 
rally undertaken  for  chronic  affections  which  cause  ulcerative  processes 
within  the  joint.  The  antiseptic  method  has  relieved  the  operation  of 
all  of  its  former  dangers.  It  is  no  longer  a  question  of  age  or  sex,  or 
even  physical  health,  but  the  decision  should  rest  entirel}'  upon  the  deter- 
mination of  tiie  nature'of  the  disease  and  its  final  results  ujjon  the  use- 
fulness of  the  limb. 

The  following  suggestions  as  to  the  extent  of  the  excision  are  import- 
ant: The  patella  should  not  be  removed,  unless  diseased,  as  it  is  essential 
to  the  formation  of  a  firm,  wcll-a23i)lied  flaj)  ;  if  carious,  the  diseased 
part  may  be  removed  with  the  gouge  or  forceps ;  in  excision  of  the  knee- 
joint  in  children  remove  at  first  a  thin  slice  of  bone,  and,  in  case  this 


800 


OPERATIVE  SURGERY. 


should  not  suffi(!e,  with  tlie  gouge  scrape  out  carefully  the  softened  and 
broken-down  osseous  tissue,  leaving  tlie  niucli-thinued  cortical  substance, 
with  tlie  periosteum,  behind  ;  the  cpi2)hyseal  cartilage  is  often  by  this 
means  laid  entirely  bare  from  the  side  of  the  Joint  ;  if  perforated  with 
fistulous  openings,  a  small  s|)oon  must  be  introduced  and  every  particle 
of  diseased  tissue  removed;  in  very  young  (•hildrcn  it  will  often  even 
not  be  necessary  to  remove  any  part  of  the  tibia  with  the  saw,  it  being 
practicable  to  remove  the  diseased  part  with  the  spoon  ;  if  the  epiphyseal 
cartilage  can  be  saved  only  in  part,  no  more  should  be  sac'rificed  than  is 
actually  necessary. 

The  method  of  operating  will  dc|icud  upon  the  kind  of  joint  sought 
to  be  obtained  :  if  union  of  the  excised  bones  is  necessary,  the  U-sha|)ed 
incision  is  in  general  preferable  to  others,  as  it  permits  the  removal  tA' 
any  necessary  amount  of  bone  without  injuring  the  soft  parts,  and  both 
corners  of  the  wound  are  situated  as  low  as  the  anatomical  conditions 
will  allow.  If  an  attempt  is  made  to  retain  motion,  a  lateral  incision  is 
to  be  preferred,  wiiich  admits  of  exseetion  witii  the  least  destruction  of 
the  ligamentous  tissues  of  the  joint.  The  amount  of  bone  removed 
must,  of  course,  depend  npon  the  extent  of  the  disease. 

Exsect  as  follows :  The  leg  being  slightly  flexed  on  the  thigh,  make 
a  curved  incision,  commencing  at  the  insertion  of  the  internal  lateral 
ligament  into  the  inner  condyle  of  the  femur,  and,  passing  just  below 
the  lower  extremity  of  the  patella,  terminate  it  at  the  same  point  on  the 
external  aspect  of  the  joint ;  the  lateral  incisions  should  not  be  made 
lower  than  the  insertion  of  the  lateral  ligaments,  to  avoid  division  of  the 
articular  arteries  ;  reflect  this  flap  upward  (Fig.  314)  ;  remove  the  patella, 
if  diseased  ;  if  not,  leave  it  undisturbed  and  divide  the  lateral  and  inter- 
articular  ligaments ;  pass  a  fold  of  antiseptic  gauze  through  the  joint, 


Fig.  314. 


Fig.  315. 


Excision  of  knee. 


Excision  of  tlie  knee  by  tlie  sawing  of  the  tibia  (Treves). 


and  draw  it  firmly  under  the  extremity  of  the  bone  to  be  sawn,  thus 
completely  isolating  the  soft  parts  behind  ;  apply  the  saw  first  to  the 
extremity  of  the  femur,  and  then  to  the  articular  head  of  the  til)ia. 


RESECTION  OF  BONES. 


801 


The  position  of  the  saw  should  not  deviate  from  a  right  angle  to  the 
shaft  of  the  bones,  so  that  when  union  takes  place  the  liml)  will  be 
nearly  straight  (Fig.  315).  The  hones  must  be  maintained  in  apposition 
by  two  or  three  silver  wires,  which  should  now  be  introduced  into  th(^ 
anterior  part  of  the  tibia  and  femur,  and,  when  sufficiently  twisted,  cut 
off  and  the  ends  turned  down  between  the  bones.  To  fix  the  bones  in 
position  use  has  been  made  of  nails,  wiiich  are  removed  at  the  end  of  two 
or  three  weeks. 

The  dressings  should  be  antiseptic — viz.  layers  of  iodoform  gauze 
next  to  the  wound,  tJieii  gauze  Ijandagcs  treated  with  bichloride  solution, 
next  borated  cotton  firmly  bound  by  gauze  bandages,  and  last  a  wire 
splint  retained  by  gypsum  bandages  to  immobilize  parts  above  and 
below  the  knee.  The  knee  itself  should  be  so  protected  that  it  can  be 
examined  without  disturbing  tlie  other  dressings.  The  more  superficial 
dressings  should  extend  from  tlic  hip  to  the  ankle.  The  limb  should 
now  be  iilaccd  in  a  sling.  The  dressings  should  not  be  changed,  except 
to  remove  the  drainase-tube,  for  several  weeks.  The  wires  are  allowed 
to  remain,  but  nails  must  be  withdrawn  after  several  weeks. 

The  folloMing  dressing  can  be  readily  applied  :  IMake  a  wooden  con- 
cave splint  to  the  calf  of  the  leg  and  back  of  thigh,  but  narrow  at  the 
knee ;  also,  if  possible,  an  iron  rod  fi>r  suspension.  Apply  the  dressing 
thus :  Pad  the  posterior  splint  with  lint  or  cotton-wool,  and  cover  that 
part  corresp(inding  to  the  site  of  the  wound  with  gutta-percha  cloth  or 
hot  paraffin ;  place  the  limb  in  position  and  carefully  adjust  it ;  place 

Fig.  316. 


Suspension  of  leg. 


the  iron  rod  on  the  front  and  lay  folded  lint  between  it  and  the  limb  at 
the  groin,  at  the  upper  part  of  the  tibia,  and  at  the  bend  of  the  ankle ; 
apply  an  open  woven  roller  bandage  around  the  whole  dressing  from  the 
toes  upward  except  at  the  site  of  the  wound  ;  over  this  apply  the  gyp- 
sum l)andage  in  two  or  three  layers  ;  when  tlie  dressing  is  firm  suspend 
tlie  limb  l)y  the  hooks;  the  wounds  may  now  be  dressed  \vithout  dis- 
turbing the  ])art. 

The  patcUu,  though  in  immediate  relation  with  the  knee-joint,  may 
be  exci.sed  with  good  results.  Make  a  crucial  incision,  the  transverse 
branch  being  over  the  base  of  the  bone,  or  a  second  transverse  incision 
may  be  made  near  the  apex  ;  dissect  tlie  flaps  off  cautiously,  and  remove 

Vol.  I. — 51 


802  OPKRATJVE  SURGERY. 

tlic  hone  or  its  frasjincnts  ;  tlic  t('ii<liiii)iis  expansion  surroiinrlinji:  tlio  hone 
should  1)0  se|)aratt'(l,  and  not  di\i<l('<l,  as  far  as  possihle.  The  antis('|)tit; 
method  shonld  he  strictly  juirsned,  and  the  iodoform  dressinjrs  a]i|)lied. 
It  the  tVai;nients  of  hone  are  not  too  nuieh  detached,  they  may  he  united 
witii  catgut  sutures  and  union  secaired. 

T\\Q  femur  is  the  largest  bone  of  the  skeleton.  Resection  of  different 
portions  of  the  bone  ui'e  very  frequent  and  give  satisfactory  results,  espe- 
cially when  the  periosteum  is  preserved,  as  new  bone  is  reproduced.  The 
lower  extremity  is  rarely  removed,  except  in  exsections  of  the  knee-joint. 
When  it  is  necessary  to  (ji)erate  for  necrosis  in  this  region  tiie  sinuses  are 
the  safest  guides  to  tlie  dead  bone.  The  shaft  of  the  femur  gives  attach- 
ment to  muscles  tliroughout  nearly  its  entire  extent,  and  to  reach  it  with- 
out injury  to  the  soft  parts  the  museular  septa  must  be  followed,  either 
along  the  antero-external  region  of  the  limb  or  as  indicated  liv  the  seat 
of  the  disease.  The  limb  must  l)e  well  supported  by  the  firm  gvjisum 
dressing  during  the  after-treatment.  The  trochanter  major  gives  attach- 
ment to  the  gluteus  medius  and  minimus,  and  by  its  fossa  to  the  external 
rotators.  In  resection  make  a  free  crucial  incision  through  the  skin  and 
tendon  of  the  gluteus  maximus,  and  when  the  surface  is  sufficiently  ex- 
posed use  the  sharp  spoon  to  remove  diseased  parts. 

The  Itip-joiiit  is  a  large  ball-and-socket  joint  in  which  the  globular 
head  of  the  femur  is  received  into  the  acetabulum  or  cotyloid  cavity  of 
the  innominate  bone :  this  articulating  surface  is  deepened  by  a  broad, 
ribbon-shaped  cartilage  occupying  the  upper  and  outer  part  and  folded 
round  a  depression  ^\■llich,  extending  from  the  notch,  is  hollowed  out  in 
the  bottom  of  the  eayity,  and  is  occu})ied  by  delicate  adipose  tissue  cov- 
ered with  syni>vial  membrane ;  the  articulating  surface  of  the  femur 
presents  a  little  beneath  its  centre  a  pit  in  which  the  round  ligament  is 
attached  ;  movement  is  allowed  in  every  direction,  extension  being  limited 
by  the  anterior  fibres  of  the  capsular  ligament,  and  flexion  by  the  con- 
tact of  the  neck  of  the  femur  with  the  acetabulum.  The  extent  of  the 
resection  should  depend  upon  the  amount  of  disease;  if  limited  to  the 
head,  that  part  alone  should  be  removed  ;  if  the  neck  is  carious,  the 
trochanter  may  still  be  preserved  ;  but  if  the  latter  is  involved,  the  bone 
must  be  divided  at  the   trochanter  minor. 

The  methods  of  operating  are  numerous,  but  the  single  incision,  with 
subperiosteal  removal  of  the  bone,  most  nearly  meets  the  anatomical 
indication  of  the  ])art.  Of  the  several  arteries  distributed  to  this 
region — namely,  the  gluteal,  sciatic,  obturator,  external  and  internal 
circumflex,  and  the  superior  perforating  l)y  anastomosis — the  only  one 
which  approaches  the  line  of  this  incision  near  enough  to  be  incised 
before  dividing  into  branches  of  distribution  too  small  to  give  rise  to' 
noticeable  hemorrhage  is  a  twig  of  the  internal  circumflex,  which  at 
one-eighth  to  one-fourth  of  an  inch  from  the  insertion  of  the  obturator 
extermis  breaks  up  into  its  terminal  divisions  ;  this  branch  may  be 
avoided  by  keeping  the  jKiint  of  the  knife  well  against  the  bone,  and 
dividing  the  tendon  of  the  obturator  externus  muscle  in  the  digital 
fossa. 

The  patient  lying  on  the  sound  side,  with  a  strong  knife  commence 
an  incision,  A  (Fig.  317),  at  a  point  midway  between  the  anterior  infe- 
rior spinous  process  of  the  ilium  and  the  top   of  the  great  trochanter ; 


RESECTION  OF  BONES. 


803 


carrv  it  in  a  curved  line  over  the  ilium  in  contact  with  the  bone,  aero:is 
to  tlie  top  of  the  great  trochanter;  extend  it  not  directly  over  the  centre 


Fig.  318. 


Excision  of  the  hip;  A.  Sayrc;  B,  Oilier. 


Passing  chain  saw. 


of  the  trochanter,  hut  midway  hetween  the  centre  and  its  jw.^tcrior  bor- 
der ;  complete  it  by  carrying  the  knife  forward  and  inward,  making  the 
whole  length  of  the  inci-sion  four  to  six  or  eight  inches,  according  to 
the  size  of  the  thigh  ;  if  the  periosteum  has  not  been  divided  by  the  first 
incision,  carry  the  point  of  the  knife  along  the  same  line  a  second  or 
tliiril  time  ;  an  assistant  separating  the  wound  with  the  fingers  or  retrac- 

Fio.  319. 


Dressing  in  hip-joint  abscess,  with  elastic  appliiMl.    Tlie  same  dressing  is  adaptcil  to  excision :  the 
position  of  the  drain  is  seen  (Cheyne). 


tors,  the  great  trochanter,  h  (Fig.  318),  is  exposed  ;  with  a  narrow,  thick 
knife  make  an  incisictn  through  the  periosteum  only  at  right  angles  with 


804 


OPERA  TIVE  S  Un  CER  Y. 


the  first  at  a  point  an  incli  or  an  iiicli  and  a  half  below  tlic  top  of  tlie 
irroat  trochanter,  opjjosite  or  a  little  above  the  lesser  troehanter,  and 
oxteud  it  as  far  as  jiossible  around  the  bone,  making  sure  that  the  peri- 
osteum is  freely  divided  ;  at  the  junction  of  the  two  ineisions  of  the 
periosteum  introduce  the  blade  of  the  ])eriosteal  elevator,  and  srradually 
peel  up  the  periosteum  from  either  side  witli  its  fibrous  attariuiirnts  until 
the  digital  foss;i  has  been  reached;  with  the  ])oint  of  the  knife  applied 
to  the  bone  divide  the  attachments  of  the  rotator  muscle,  and  continue 
to  elevate  the  periosteum,  carefully  avoiding  rupturing  it  at  any  point ; 
when  the  periosteum  is  removed  as  far  as  necessary,  adduct  the  limb' 
sliglitly,  depress  the  lower  end  of  the  fenuu-  sufficient  to  allow  the  head 
of  tiie  bone  to  be  lifted  out  only  so  far  as  is  reijuisite  to  ])ermit  its 
removal  with  the  saw,//;  divide  the  bone  just  above  the  trochanter 
minor  and  remove  the  fragment ;  if  the  head  of  the  bone  cannot  be 
raised  before  division  on  account  of  the  involucrura,  saw  the  bone  first 
and  then  remove  the  head ;  if  the  shaft  at  the  point  of  section  is 
necrosed,  expose  and  exsect  more  ;  examine  the  acetabulum,  and  if  found 
diseased  remove  all  dead  l)one;  if  perforated,  the  internal  ])criostcum 
will  be  found  peeled  off,  making  a  kind  of  cavity  behind  the  acetabulum, 
and  all  diseased  bone  must  be  very  carefully  chipjicd  otf  down  to  the 
point  where  the  pei'iosteum  is  reflected  from  sound  bone.  P]very  part 
of  the  wound  and  all  sinuses  must  be  thoi'oughly  cleaned  of  ])articles 
of  bone  and  false  membrane.  Or,  make  an  incision,  B  (Fig.  -jIT),  com- 
mencing about  three  inches  below  the  crest  of  the  ilium,  and  at  the  same 
distance  posterior  to  the  antt-rior  superior  spine,  downward  to  the  tro- 
chanter major,  and  then  along  the  centre  of  the 
shaft  of  the  bone,  and  proceed  as  above. 

The  dressings  of  the  wound  are  as  follows  :  In- 
troduce the  drainage-tube  to  the  bottom,  then  pack 
the  wound  with  iodoform  gauze,  or  close  the  wound 
^vith  sutures  to  the  tul)e  and  apply  iodoform-gauze 
pails.  Enveloj)  all  with  a  wide  and  thick  layer  of 
borated  cotton  and  apply  the  gauze  bandage  firmly. 
Place  the  patient  on  a  smooth  mattress  and  make 
extension  at  the  foot  with  a  six-pound  weight.  The 
upright  position  of  the  foot  should  be  maintained, 
and  the  dressing  shoidd  be  changed  as  seldom  as 
possible.  When  completed  the  dressings  should 
envelop  the  upper  part  of  the  thigh,  the  hiji,  and 
pelvis  (Fig.  -319).  The  patient  should  not  attempt 
to  walk  with  crutches  until  the  external  wound  is 
quite  healed,  which  ordinarily  occurs  with  antiseptic 
treatment  in  five  or  six  weeks.  Attempts  to  bear 
weight  on  the  foot  should  not  be  encouraged  for 
six  months,  in  order  to  allow  the  fibrous  struc- 
tures to  consolidate.  During  the  period  between 
the  healing  and  using  the  limb  the  hip  splint  (Fig. 
320)  should  be  worn. 
With  children,  extension  by  the  application  of  weights  and  proper 
positions  of  the  limb  is  the  best  means:  the  patient  may  be  placed 
on  a  divided  mattress,  of  whicli  the  two  difterent  parts  are  separated 


Fig.  320. 


Hip  splint. 


RESECTION  OF  BONES.  805 

by  an  interstice  of  several  inches  exactly  corresponding  to  the  spot 
where  the  excision  was  made. 


BONES    OF   THE   TRUNK. 

The  vertehne  have  been  suljjected  to  fro(piciit  partial  resections.  The 
removal  of  loose  fragments  after  severe  injuries,  as  from  shot,  is  perfectly 
rational,  and  has  resulted  iu  a  fair  measure  of  success.  In  the  removal 
of  a  spinous  process  or  arcii  make  a  long  incision  above  the  ridge  of 
tiie  spinous  process,  the  mickUe  of  wliicli  is  opposite  the  displacement ; 
divide  all  the  attacliments  of  tiie  nuiscles  to  the  articular  processes;  as 
one  end  of  each  muscular  bundle  is  separated  from  its  attachment,  it 
retracts  and  needs  little  holding  back  ;  the  saw  or  the  nippers  are  gen- 
erally sufficient  to  divide  the  vertebral  arch ;  in  sawing  or  cutting  out 
the  arch  grasp  the  spinous  process,  if  it  l)e  not  broken,  with  a  pair  of 
stout  tooth  forceps,  which  are  to  be  preferred  to  the  elevator  for  lifting 
the  detached  bone  from  its  natural  connections  ;  a  small  crowned  trephine 
may  be  used  to  cut  through  the  vertebral  arch,  or  Hey's  saw. 

The  cocri/.v  may  be  excised  in  whole  or  part  for  necrosis,  fracture,  or 
for  a  painful  aiFection,  coccydynia,  thus :  Place  the  patient  on  the  side, 
the  thighs  flexed,  and  the  hips  close  to  the  edge  of  the  bed ;  the  buttocks 
being  separated,  make  an  incision  in  the  median  line  extending  from  the 
extremitv  of  the  coccyx  upward  to  the  re(piisite  extent ;  remove  the  dis- 
eased bone  either  with  the  gouge  or  the  drill,  or  the  bone  maybe  divided 
with  the  cutting  forceps.  The  fore  finger  in  the  rectum  determines  the 
progress  and  extent  of  the  resection. 

The  ribs  are  closely  invested  on  their  internal  surface  by  the  pleura, 
and  along  the  groove  on  the  lower  liorder  runs  the  intercostal  artery. 
The  only  admissible  primary  interference  when  the  ribs  are  fractured  by 
balls  is  the  extraction  of  loose  fragments  and  the  smoothing  oti' of  sharp- 
pointed  ends.  Resection  for  necrosis  slK)uld  be  made  by  opening  existing 
sinuses  and  carefully  separating  the  thickened  periosteum  with  the  pleura. 
In  the  removal  of  morbid  growths  portions  of  ribs  may  require  resection ; 
great  care  must  be  taken  to  separate  the  pleura  with  the  periosteum  with- 
out wounding  the  former.  Proceed  as  follows :  Place  the  patient  upon 
the  sound  side,  and  expose  the  bone  by  an  incision  along  tlie  middle  of 
the  rib,  or  the  incision  may  be  curved  downward  :  divide  the  intercostal 
muscles  and  disengage  the  intercostal  artery  from  its  groove  in  the  in- 
ferior border  of  the  bone  ;  separate  the  pleura  cautiously  with  the  handle 
of  the  scalpel  or  similar  instrument,  ami  pass  a  thin  piece  of  antiseptic 
pasteboard  or  other  substance  behind;  divide  the  bone  with  the  chain 
saw.  Section  of  the  posterior  part  of  the  ril)  may  be  first  made  to  avoid 
wounding  the  pleui-a ;  scrape  carefully  each  border  of  the  bone,  and  do 
not  incline  the  point  of  the  knife  toward  the  intercostal  sjiace.  In  re- 
moving the  false  ribs  support  the  free  extremity  while  the  rib  is  divided 
posteriorly.  The  costal  cartilage  may  be  removed  by  an  incision  along 
its  centre  and  vertical  incisions  at  each  extremity. 

The  stern  inn  has  been  frequently  ])artially  resected  for  shot  injuries, 
and  with  verv  favorable  results,  the  mortality  being  very  slight.  When 
subperiosteal  resection  has  been  made  for  necrosis  new  bone  has  been 
reproduced.     The  incision  for  resection  may  be  crucial  or  vertical,  accord- 


806  OPERATIVE  SURGERY. 

ing  to  the  extent  of  injury  or  disease,  and  the  parts  may  be  removed  by 
the  trepiiine,  gouge,  or  forceps.  Tlie  iijiper  jiortion  may  lie  removed  l)y 
a  vertical  incision,  with  transverse  incisions  at  each  extremity.     The  hone 

is  divided  witli  a  saw,  and  (lie  costal  carti- 
'"■  ^^^'  lages   with  a  strong  scalpel   from   before 
- backward  (Fig.  321). 

,•■"■■;;;."■  bones  oy  the  face. 

•- ■"'.  In  resection  operations  on  the  bones  of 

the  face  it  is  important  to  avoid,  as  far  as 

25*'^''*'ble,   incisions   which   will    leave    un- 

./         C sightly  scars  and   the  removal  of  bones 

;"'...-.:         .!," "     which  destroy  the  symmetry  of  the  fea- 

'•-,"""■--.,.  tures.     When  praetical)le,  ])erform  intrn- 

..■••■■'_..-•'.'         ■■••■..""■■■■■..       i    buccal  resections  witliout  extcnjal  incision  ; 

...■•'''/■,        ..'•-/" "    make  incisions  along  the  natural  folds  of 

//['•■     K  ' '■■..   "■•-  skin  and  preserve  borders  of  the  mouth 

■  /./      ...'   \    '■...  from  division  ;  in  all  eases  that  admit  of 

subperiosteal  resection  this  method  is  to 

Incision  for  resection  of  upper  part  of    ]jg   preferred 

sternum.  J  ,         .    j.    '.  .„      .  ..    ,  i 

ine  nijenor  maxilla  is  very  liable  to 
injury  and  necrosis  and  to  be  the  seat  of  morliid  growths.  In  com- 
minuted fractures  the  fragments  should  be  preserved  unless  quite 
detached,  as  they  have  great  vitality  and  are  important  in  the  pre- 
servation of  the  contour  of  the  jaw.  For  necrosis  the  resection 
should  as  far  as  possible  be  subperiosteal  and  intral)iiccal,  and  both 
objects  may  often  be  accomplished  by  occasionally  aiding  the  slow  pro- 
cess of  separation  of  the  necrotic  l)one  from  its  attaclunents  to  bone 
and  periosteum  with  the  elevator  or  the  handle  of  the  scalpel  or  a 
spatula.  By  degrees  the  sequestrum  is  loosened,  new  bone  forms  around 
it  from  the  periosteum,  and  eventually  the  dead  bone  may  be  lifted  from 
its  bed  with  perhaps  slight  incisions  of  the  gum  ;  liy  this  method  large 
portions  of  the  jaw,  and  even  the  entire  jaw,  may  be  rejiroduced  during 
the  process  of  sequestration,  and  not  (inly  its  coutDur,  but  its  function,  be 
preserved.  This  method  is  preferable  to  early  resection,  which  is  liable 
to  be  followed  by  great  contraction  of  the  parts,  even  if  the  periosteum  is 
preserved  and  new  bone  is  produced.  In  resection  for  tumors  ample 
external  incisions  are  often  recjuired,  and  large  portions  of  tlie  bone  must 
be  sacrificed.  But  small  tumors,  involving  only  the  alveolus,  may  be 
removed  with  bone  forceps  without  incision  of  the  skin.  A  considerable 
portion  of  the  central  jiart  of  the  jaw  may  be  removed  without  incising 
the  lip  if  the  mucous  membrane  is  freely  divided  between  it  and  the  bone 
and  the  lip  is  drawn  well  down.  The  wound  must  be  disinfected  with  a 
weak  bichloride  solution,  1  :  5000,  care  being  taken  to  prevent  its  entering 
the  stomach.  In  closing  these  wounds  endeavor  to  unite  first  the  cut  sur- 
faces of  the  mucous  membrane  by  sutures  so  applied  as  to  cause  slight 
evei'sion  of  the  free  margins  into  tlie  mouth.  Tiien  accurately  close  the 
external  wound,  using  catgut  drains,  and  ajiply  iodoform  dressings. 

(o)  When  the  central  part  is  to  be  resected  jiroeeed  as  follows :  Pass 
a  stout  ligature  through  the  tip  of  the  tongue  to  hold  it  in  position  when 


RESECTION  OF  BOXES. 


807 


Fig.  322. 


AB,  incision  for  resection  of  the  middle 
iiart  of  tlie  body  of  the  lower  jaw  (Cha- 
lot). 


the  muf-fles  are  incised ;  an  assistant,  standing-  beliiud  the  patient,  holds 

liis  heail  tirnily  uinl   compresses  tiie  two  tai'ial  arteries  at  the  points 

where  they  cross  the  lower  jaw.     Standing  in  front,  seize  with  the  left 

hand  one  of  the  angles  of  the  lower 

lip,  while  an  assistant  holds  the  other 

angle  from  the  bone  and  the  whole  in 

a  state  of  tension  ;  dividi'  the  lip  witii 

a  vertical  incision  tlirough  the  median 

line    down    to    the    os    hvoides,  thns 

making  flaps. 

Or  make  a  single  curved  incision 
along  the  lower  margin  of  the  jaw ; 
raise  the  periosteum  from  the  bone  to 
be  removed  ;  extract  a  tooth  opposite 
to  each  point  where  bone  is  to  be  sawn 
through  ;  use  a  small  Hey's  saw  or 
the  chain  saw ;  the  bone  being  sawn 
through  on  both  sides,  divide  the  mus- 
cles attached  to  it  as  closely  as  possible 
to  their  insertion,  carrying  the  knife 
along  the  concave  surface  (Fig.  .'322). 
Unite  the  two  flaps  with  silver-wire 
sutures  passed  through  to  the  mucous 
membrane,  adjusting  tlie  margins  of 
the  lip  ;  or  use  the  hare-lip  pins  with 
tigure-of-8  suture  if  there  is  much  tension  ;  attach  the  ligature  holding 
the  tongue  to  a  fohl  of  adhesive  strip  firmly  fastened. 

(6)  The  horizontal  portion  has  the  following  anatomical  parts  to  be 
considered  :  Attached  on  its  internal  surface  is  the  mylo-hyoideus  muscle, 
beneath  which  is  the  fossa  for  the  submaxillary  gland  ;  on  its  external 
surface  along  its  lower  margin  is  the  attachment  of  the  platysma  myoides 
muscle,  and  along  its  alveolar  margin  the  buccinator ;  tlie  facial  artery 
mounts  over  its  lower  Ixu-der  just  anterior  to  the  insertion  of  the  mas- 
.seter  muscle.  Resect  as  follows  :  Make  an  incision  commencing  l)ehind 
and  a  little  above  the  angle,  avoiding  the  facial  nerve  and  parotid  duct 
along  the  border  of  the  jaw,  terminating  from  a  (puirter  to  half  an  inch 
below  the  symphysis  menti ;  raise  and  reflect  the  flaj)  on  the  face,  tying 
botli  ends  of  the  divided  facial  artery  ;  the  bone  being  denuded  or  the 
periosteum  raised,  divitle  witli  a  chain  saw  passed  at  the  proper  point 
anteriorly,  a  tooth  being  removed  if  necessary  ;  seize  the  end  of  the  frag- 
ment with  strong  forceps,  and  divide  with  the  chain  saw  at  or  near  the 
angle,  as  may  be  required  ;  close  the  wound  firmly,  care  being  taken  to 
compress  the  surfaces  of  the  incised  mucous  membrane  closely  to  secure 
prompt  union. 

(c)  The  half  of  fhe  lower  jaw  has  the  following  additional  relations : 
The  ramus  terminates  in  two  processes,  one  for  articulation  and  the  other 
to  give  attachment  to  the  temporal  mu.scles  ;  the  articulation  is  supported 
by  an  external  and  internal  lateral  and  the  capsular  ligament ;  the  stylo- 
maxillary  ])asses  from  the  styloid  ]irocess  to  the  angle  of  the  jaw  ;  the 
internal  maxillary  artery  passes  behind  tiie  neck  of  the  condyle  in  such 
proximity  as  to  render  care  necessary  to  avoid  wounding  it  in  disartic- 


808 


OrEBATIVE  SURGERY. 


Illation  of  the  jaw.  Ri'scct  as  flillows  (Fio;.  ;52o) :  Place  the  ])atieiit  with 
the  shoulders  raised  and  head  turned  to  the  opposit(.'  side ;  eomuienee  the 
incision  at  the  zygomatic  arch  behind  the  condyle,  carry  it  downward 
behind  the  ramus  to  the  angle  and  under  the  body  of  the  bone  to  a  point 

Fig.  323. 


Excision  of  half  of  lower  Ja^^ 

one-quarter  of  an  inch  below  the  symphysis  menti  if  the  operation  is  for 
an  old  necrosis,  but  througli  the  centre  of  the  lip  if  for  the  removal  of 
bone  for  other  affections  :  in  the  former  ease  incise  the  perio.steum  and 
raise  it  from  the  bone  throughout,  but  otherwise,  for  the  removal  of  a 
tumor,  the  facial  artery  must  be  cautiously  divided  and  secured.  Sub- 
periosteal resection  may  no\v  be  rajiidly  jierformed  for  necrosis,  the  bone 
being  divided  with  the  chain  or  small  straight  back  saw,  and  the  cut  end 
used  as  a  lever  to  raise  it  from  its  position  during  the  jn'ocess  of  enu- 
cleation. If  the  periosteum  is  not  saved,  liaving  divided  the  bone,  seize 
the  cut  extremity  with  the  hand  ;  raise  it  from  its  bed,  carefully  separat- 
ing all  tissues  adherent  to  the  body  and  ramus  ;  carry  a  narrow-bladed 
knife  or  curved  scissors  beneath  the  zygomatic  arch  and  behind  the  coro- 
noid  process,  and  with  it  divide  the  tendon  of  the  temporal  muscle  while 
depressing  the  bone  to  disengage  the  jtroeess  and  luxate  the  <'ondyle ; 
]mll  the  bone  strongly  outward,  as  far  as  possible  from  the  vessels,  in 
order  to  avoid  especially  the  internal  maxillary  artery,  and  complete  the 
operation  by  dividing  the  pterygoid  muscles  and  the  articular  ligaments. 
Secure  every  bleeding  vessel  and  close  the  wound  by  carefully  adjusting 
the  margins  of  the  integument  and  of  the  mucous  membrane.  When  the 
tumor  is  large  and  completely  wedged  in  the  upper  part  of  the  bone,  so 
as  to  hinder  the  freeing  of  the  coronoid  process  and  prevent  dislocation, 
cut  otf  the  tumor  as  high  as  possible  with  the  bone  forceps  or  saw,  and 


BESECTTON  OF  BONES. 


809 


then  remove  the  remaining  portion  of  the  jaw  only  in  case  the  disease  is 
malignant. 

((/)  The  entire  lower  jaw  is  removed  as  follows :  Pass  a  ligature 
through  the  anterior  part  of  the  tongue,  and  trust  it  to  an  assistant;  make 
an  incision  commencing  opposite  the  left  condyle  downward  toward  the 
angle  of  the  jaw,  ranging  at  about  two  lines  in  front  of  tlie  posterior 
border  of  the  ramus,  thence  along  the  base,  to  terminate  at  tiie  median 
line  a  little  posterior  to  the  most  prominent  part  of  the  border  of  the 
jaw.  Dissect  upward  the  tissues  of  the  cheek,  and  reflect  downward, 
for  a  short  distance,  the  lower  edge  of  the  incision  ;  separate  the  tissues 
forming  the  floor  of  the  mouth,  situated  njion  the  inner  surface  of  the 
body  of  the  bone,  from  their  attachments  from  a  point  near  the  median 
line  as  far  back  as  the  angle  of  tlic  jaw  ;  next  divide  the  attachments  of 
the  buccinator ;  secure  by  ligature  the  facial  artery,  the  submental  and 
the  sublingual ;  expose  the  external  surface  of  one  branch  of  the  jaw  and 
of  the  temporo-maxillary  articulation  by  dissecting  the  masseter  upward 
as  far  as  the  zygomatic  arch  ;  seize  the  ramus  and  pull  the  coronoid  pro- 
cess downward  Ix'low  the  zygoma;  divide  the  insertion  of  the  ptery- 
goideus  intcrnus,  grazing  the  bone  in  doing  so  ;  carefully  avoid  the 
lingual  nerve,  here  in  close  proximity ;  divide  the  dental  artery  and 
nerve ;  separate  the  tissues  attached  to  the  inner  face  of  the  bone  as  high 
up  as  a  point  situated  about  a  line  below  the  sigmoid  notch,  between  the 
condyle  and  the  coronoid  process;  detach  the  tendon  of  the  temporal 
muscle  by  means  of  l)lunt  curved  scissors  or  a  probe-pointed  bistoury, 
keeping  close  to  flie  hone  ;  make  use  of  the  rannis,  now  movable,  as  a 
lever  to  aid  in  the  disarticidation  of  the  bone :  to  efiect  safely  the  tlisar- 
ticulation  of  the  condyle,  peiietrate  the  joint  by  cutting  the  ligaments 
before  backward  and  from  without  inward  ;  the  articulation  thus  opens 
sufficiently  to  allow  the  condyle  to  be  completely  luxated  ;  blunt  scissors 
may  now  be  used  to  cut  cai'efull}'  the  internal  part  of  the  capsule  and 
the  maxillary  insertion  of  the  external  pterygoid  muscle  ;  by  a  slow 
movement  of  rotation  of  the  raunis  upon  its  axis  the  condyle  is  detached 
and  the  operation  completed.  To  effect 
the  removal  of  the  other  half  make  the 
same  incision  on  the  opposite  side,  so  as  to 
meet  the  first  on  the  median  line  ;  the  dis- 
section is  similar. 

The  aupertor  maxiUa  has  the  following 
important  anatomical  features :  It  is  at- 
tached to  other  bones  at  but  three  princi- 
pal points  :  First,  by  its  ascending  process 
and  articulations  with  the  os  unguis  and 
ethmoid  ;  second,  by  the  orbital  border  of 
the  malar  as  far  as  the  spheno-maxillarv 
fissure;  third,  by  the '  articulation  of  the 
two  maxillaiy  bones  with  each  other  and 
the  palate-bone  ;  there  is  a  fourth  point  of  contact  behind  with  the  ptery- 
goid process  and  the  palate-bone,  wliich  yields  easily  by  simple  depres- 
sion of  the  maxillary  bone  into  the  interior  of  the  month  :  in  attacking 
these  different  points  no  large  vessel  is  injui-ed  ;  the  trunk  of  the  internal 
maxillary  artery  may  be  easily  avoided,  or  in  any  case  tied  after  the 


Fig.  324. 


Liiaes  of  incision  for  resection  of 
upper  jaw. 


810 


OPERA  TTVE  S  URGER  Y. 


Fig.  325. 


removal  of  the  bone  ;  moreover,  in  ca.sc  of  unforeseen  heniorrliage  during 
the  operation  we  have  a  resource  in  compression  of  the  carotid  ;  only  one 
important  nerve-trunk,  the  superior  ma.\illary,  need  be  divideil. 

Resection  of  the  bone  is  performed  for  tiie  extirpation  of  malignant 
growtLs  and  to  gain  access  to  naso-])iiarvngeal  tumors  :  in  the  former 
case  it  is  ju.stifial)lc  only  wiiere  the  disea.se  is  limited  to  the  upper  jaw 
and  its  corresponding  palate-bone,  owing  to  the  certainty  of  recurrence 
if  the  disease  extends  beyond.  The  methods  of  procedun;  are  numerous, 
and  give  great  and  desirable  latitude  to  the  operator.  Early  operators 
cut  boldly  through  the  clieck,  1  (h'ig.  o'-i-l),  but  to  avoid  unsightly  .scar.s 
the  rule  now  obtains  of  making  the  inci.sion  in  the  cour.se  of  natural 
folds  of  the  skin,  2  and  4  (Fig.  324).  Subperiosteal  resection  may  be 
made  by  these  incisions,  but  a  more  formal  operation  is  made  by  fol- 
lowing the  line  1  (Fig.  324). 

Resect  the  superior  maxilla  below  the  floor  of  tlie  orliit  by  the 
following  operation  (Guerin) :  Make  an  incision  .slightly  convex  back- 
ward, conmiencing  at  the  ala  of  the  no.se  and  terminating  at  the  cor- 
responding connnissure  of  the  lip, 
following  the  naso-labial  fold  or  fur- 
row, 4  (Fig.  324);  dissect  up  the 
two  fla])s  resulting  from  this  incision 
until  tlie  nostril  is  exixised  and  the 
malar  process  isconipletcly  denuded  ; 
witli  a  small  saw  held  in  the  right 
hand,  saw  through  the  malar  pro- 
cess from  above  downward,  and  a 
little  from  within  outward  ;  the  soft 
palate  having  been  detached  from 
the  posterior  border  of  the  palatine 
bone  by  a  transverse  incision  made 
at  the  posterior  border  of  the  last 
great  molar,  and  an  incisor  tooth 
having  been  extracted,  divide  the 
horizontal  portion  of  the  maxilla 
from  before  backward  with  cutting 
forceps,  one  branch  being  in  the 
mouth,  and  the  other  in  the  nares ; 
make  a  section  of  the  bone  from  the 
divided  malar  process  to  the  nares 
by  the  forceps ;  seize  the  bone  with 
•strong  forceps,  and  remove,  fractur- 
ing the  pterygoid  jirocess  (Fig.  325). 
After  thorough  disinfection  of  the 
wound  apply  iodoform  dressings. 

The  entire  maxilla  or  portions 
may  be  resected  as  follows  :  Exti-act 
the  incLsor  teeth  of  that  side  ;  divide  the  upper  lip  in  tlie  median  line 
to  the  nostril ;  continue  the  incision  around  the  ala  and  up  the  side  of 
the  nose  toward  the  inner  canthus  of  the  eye,  thence  continue  it  in  a 
slight  curve  below  the  orbit,  2  (Fig.  324),  or  to  the  malar  bone ;  reflect 
the  skin  from  the  bone,  and  with  a  narrow  saw  passed  into  the  no.stril 


Method  of  removing  the  resected  portiou 
(Farabeuf). 


AMPVTATION. 


811 


divide  the  alveolus  and  hard  palate  ;  incise  the  imieous  menihrane  of  the 
mouth  as  far  back  as  the  soft  palate  ;  cut  partially  also  the  malar  process 
of  the  maxillary  bone,  or,  if  necessary,  the  bone  itself,  and  the  nasal  pro- 
cess of  the  superior  maxilla,  and  complete  the  division  of  these  bones 
with  the  forceps ;  grasp  the  bone  with  the  lion  forceps  and  detach  it 
forcibly  from  the  pteryyoid  process  and  palate-bone;  when  the  bone  is 
loose  raise  the  fascia  t)f  the  orbital  palate,  si'parate  the  infra-orbital  nerve, 
the  soft  palate,  and  any  adhering  tissues.  The  hemorrhage  must  be  sup- 
pressed by  ligatures  and  the  actual  cauteiy,  and  the  wound  adjusted  at 
the  lips  by  hare-lip  pins  and  in  other  parts  by  carl)olized  silk  sutures. 
The  KUpcvior  ma.rilke  may  be  removed  at  a  single  oju'ratinn  by  an 
incision,  3  (Fig.  324),  along  the  centre  of  the  nose  and  through  the  ujiper 
lip;  additional  incisions  may  be  made,  if  rc(iuired,  under  the  orbit  later- 
ally. Or,  a  fonr-cornereil  tlap  may  be  made  by  an  incision  on  either  side 
from  the  angles  of  the  mouth  to  the  external  angles  of  the  eye,  1  (Fig.  324). 
The  divisions  of  the  bone  by  the  different  operations  are  instructively 
shown  by  Treves. 

Fig.  326. 


Saw  incisions  in  the  maxilte:  A,  B,  C.  excision  of  the  upper  jaw;  /),  Boeckel's  operation  (nasal 
polypusi;  E,  V.  Guerin's /iperation  (partial  excision);  F,  F,  Langenbecl<'s  operation  (nasal 
Ii:>lypusi;  li.  excision  of  lower  jaw  ;  if,  removal  of  portion  of  alveolus  ;  J,  Esmarch's  opera- 
tion (anlij-losis  of  Jaw)  (Treves). 

The  Extremities. 

Amputation. 
An  amputation  is  required  only  when  the  question  of  recovery  by  other 
means  is  negatived  beyond  all  reasonable  doubt,  or  when  the  presence  of 


812 


OPERATIVE  8VRQERY. 


Fi(i.  327. 


an  incurable  disease  is  a  source  of  such  evil  or  discomfort  as  to  render  the 
loss  of  the  limb  desirable  or  beneficial  to  the  patient.  The  Knal  judg- 
ment as  to  the  necessity  of  an  ani])utation  in  any  given  case  must  be 
sustained  bv  the  latest  sui'uical  ('\|i(  liencc,  for  an  amputation  that  would 
formerly  have  been  justified  would  now  be  repudiated  liy  the  best  au- 
thorities, and  the  o])crator  justly  charged  with 
ignorance  and  unskilfulness. 

The  instruments  required  to  form  a  complete 
amjnitating  case  are  a  long  and  short  knife  and 
catling  (Fig.  •527),  metacarpal  saw,  scalpel,  te- 
iiaculuin,  saw,  bone  forceps,  artery  forceps,  need-. 
Ics,  t()m'ni(|uet,  and  elastii'  bandage.  The  knife 
should  be  al)out  twice  the  length  of  the  diam- 
eter of  the  limb.  The  catling  is  a  double-edged 
knife,  the  two  edges  being  parallel  until  they 
converge  to  form  the  point  ;  the  scalpel  is  large 
and  strong,  having  a  firm  handle.  The  saw 
(Fig.  328)  should  have  a  strong  back  and  be 
well  set.  The  Ixtne  forceps  shotdd  lie  cutting. 
.  The  tourniquet  should  be  strong  (Fig.  203), 

I  I         ''"'•^  applied  as  in  Fig.  204.     The  clastic  band- 

'  lli         ^>^'^  '^  '^^'^'"  *"  ^'^'  ^*^*^'  ^"*"^  '^''  apjilication  in 

Fig.  201.  The  artery  forceps  may  be  dog- 
toothed  (Fig.  206)  or  with  a  slide.  There 
should  be  six  or  more  catch  forceps  (Fig.  207). 
The  time  of  tlie  operation  must  be  fixed  with 
due  regard  to  the  cause  which  necessitates  the 
amputation  and  the  condition  of  the  jiatient. 
There  is  a  time  when  interference  nuist  be 
avoided  rather  than  courted,  but  the  limits  of 
the  two  periods  are  not  always  ^\'cll  defined, 
and  must  be  left  to  the  judgment  of  the  sur- 
geon in  each  individual  case.  In  general,  it 
may  be  advised,  thus:  (1)  injuries  necessitate 
inunediatc  amputations,  but  the  ojx'ration 
should  not  be  performed  during  the  period 
of  reaction  from  shock  ;  (2)  if  the  disease  is 
acute,  avoid  the  period  of  active  inflammation 
and  rapidly-spreading  gangrene  ;  (3)  in  chronic 
affections  the  surgeon  should  regulate  the  time 
of  operation  according  to  the  j)rinciplcs  detailed. 
Tlie  jildce  of  (imputation  must  be  deter- 
mined with  regard  (1)  to  the  safety  of  the 
])atient,  and  (2)  to  the  serviceableness  of  the 
resulting  limb.  Divisions  of  amputations 
based  on  the  place  of  operation — namely,  (1) 
in  the  continuity  of  the  shaft;  (2)  in  the  con- 
V)ones — are  now  comparatively  unimportant,  as 
experience  proves  that  both  for  safety  to  the  patient  and  servicealileness 
of  stump  no  distinction  should  be  made  between  amputation  in  the  con- 
tinuity and  contiguity,  with  the  exception  of  the  ankle.     In  the  upper 


X3r 

Antiseptic    knives, 
handles. 

tiguity  or  articulation  of 


AMPUTATIOX. 


813 


extreraitv  all  the  conditions  unite  in  favor  of  tlie  least  possible  sacrifice 
of  parts,  for  the  safety  (tf  the  jiatient  is  in  j)rop()rtit)n  to  the  distance  of 
the  wound  from  the  Ijody  ;  and  tlie  vahie  of  tiie  stump  in  preliension 
depends  upon  the  number  of  articulations  preserved.  In  the  lower 
extremity  the  same  rule  applies  to  the  wound,  but  as  the  stump  is  to 
be  used  in  locomotion,  it  rc(|uires  breadth  and  firmness  to  sustain  con- 
tact witli  the  artificial  appliances  used  in  jtrojiression,  and  hence  a  place 
of  amputation  must  be  selected  which  will  secure  tlu'sc  conditions.  TJiis 
place  is  not  always  the  farthest  point  from  the  trunk  at  wliich  an  am2)u- 
tation  could  be  performed  in  a  given  case.  But  in  practice  it  is  not 
difficult  to  harmonize  the  two  indications  :  when  the  amputation  nearer 
the  trunk  would  give  the  better  stump,  the  danger  of  the  wound  is  not 


Fig.  328. 


■^  ^v^■^^v.^^vwvAWvw^^vw^AvAVW>AAA^A^^^v/AV.^^A^J^^^/A^^Av 


.Amputating  saw. 

SO  much  greater,  generally,  as  to  forbid  accepting  the  sliglitly  increased 
risk  for  the  lifelong  ail  vantage  gained. 

Tlie  immediate  pvepumfion  for  an  amputation  should  include  all  of  the 
appliances  necessary  to  render  the  wound  entirely  aseptic,  as  fully  stated 
in  the  section  giving  the  details  of  an  antiseptic  operation.  The  limb  to 
be  amj)utated  shoulil  l)e  scrupulously  cleansed,  disinfected,  and  shaved  as 
directed  on  the  day  preceding  tiie  operation.  When  other  preparations 
are  comjjlete,  apply  the  elastic  liandage  from  the  extremity  to  a  point 
sufficiently  above  the  place  of  the  division  of  the  bone  to  pi'event  its 
interfering  with  the  formation  of  the  flaps  (Fig.  329). 

Fig.  329. 


Elastic  bandage  in  amputation  at  the  knee-joint. 

Tlie  method  of  operation  should  aim  to  secure  a  well-nourished  cover- 
ing of  the  stump,  neither  scant}'  nor  redundant,  and  freely  movable 
cicatricial  tissue.  To  obtain  such  results,  (1)  the  soft  parts  must  be  very 
nicely  adapted  to  the  surface  to  be  covered  and  well  supjilied  with  blood- 
vessels ;  (2)  the  cut  surface  of  bone  must  l)e  immediately  covered  by  tlie 
pericsteum  or  the  deep  fascia  of  the  part,  iu  order  to  pre\-cnt  the  super- 


814  OPERATIVE  SUROEBY. 

ficial  fiiscia  and  intfwtiniciit  from  hccominfi;  too  firmly  attaflicd  liy  the 
cicatricial  tissue  to  tiic  cirI  of  the  hone.  Tliese  resiihs  are  secured  hy 
raisiufi'  tlie  periosteum  with  the  soft  tissues  and  applying  it  to  the  cut 
end  of  the  bone.  The  objection  to  the  periosteal  covering  of  the  bone 
that  osteophytes  are  liable  to  form  on  the  extremity  and  render  the 
stump  tender  are  trivial  wlien  C()m])ared  with  the  advantages  which  fol- 
low the  protection  wliieii  it  affords  from  necrosis  and  osteomyelitis,  and 
the  l)asis  which  it  forms  for  a  moval)lc  covering.  If  osteoi)hytcs  become 
tronblesome,  they  may  readily  be  removed  bj'  a  slight  operation.  It  also 
freipiently  happens  that  the  mutilation  of  parts  by  the  injury  is  so  great 
that  the  surgeon  can  form  the  coverings  of  the  stump  by  no  fixed  rules, 
but  must  exercise  his  ingenuity  in  ])atchwork.  If  the  conditions  essen- 
tial to  a  sound  and  useful  stump  are  constantly  kcj)t  in  view,  any  of  the 
stereotyped  or  extemporized  methods  may,  with  ])atience  and  dexterity, 
be  made  to  yield  good  results.  The  recognized  methods  of  amputation 
are:  (1)  the  circular  ;  (2)  the  single  flap  ;  (3)  the  double  flap  ;  (4)  the 
rectangular  flap  ;  (5)  the  bilateral  flap  ;  (0)  the  periosteal  flap. 

The  circular  operation  can  be  executed  more  quickly  by  the  following 
than  by  the  ordinary  method  :  Stand  u])ou  the  right  side  of  the  limb, 
the  left  foot  thrown  forward  and  placed  fii'mly  upon  tiie  floor,  the  right 
knee  bending  sutticiently  to  give  freedom  of  motion  to  the  body;  grasp 
the  limb  above  the  jioint  of  operation  with  the  left  hand,  and  take  the 
handle  of  the  knife  l)etwecn  the  thumb  and  fore  and  second  fingers  of 
the  right  hand,  lightly  supported  by  the  other  fingers;  stoojiing  suffi- 
ciently to  allow  the  right  arm  to  encircle  the  limb  readily,  carry  the 
knife  around  until  the  blade  is  nearly  perpendicular  to  tiie  long  axis  of 
the  limb  on  the  side  next  to  you  with  the  point  downward  and  the  hand 
above  the  limb.  Commence  the  cut  \\\{\\  the  heel  of  the  knife,  giving 
slightly  sawing  motions,  and  bring  the  hand  under  the  limb,  and  then 
directly  njiward  upon  the  side  next  to  you,  until  the  heej  touches  the 
point  of  commencement ;  the  handle  of  the  knife  held  thus  delicately 
will  change  its  relative  positions  as  it  passes  around  the  linili  without  the 
slightest  embarrassment  to  the  operator.  The  ease  with  which  the  incision 
is  completed  will  depend  much  upon  whether  it  commences  ^^•ell  down 
upon  the  side  of  the  limb  next  to  the  ojierator ;  raise  the  skin  from  the 
first  layer  of  muscles  by  dissection,  and  turn  it  upward,  t\vo  or  three 
inches  according  to  the  diameter  of  the  limb,  like  the  cutt'  of  a  coat. 
Divide  the  first  layer  of  muscles  at  the  margin  of  the  retracted  integu- 
ment by  the  cir<'ular  incision,  as  of  the  skin  ;  raise  this  layer  with  the 
knife  and  draw  it  still  farther  upward  ;  divide  the  last  layer  of  muscles 
down  to  the  bone  (Fig.  330)  by  the  same  sweep  of  the  knife  as  before 
given.     Saw  the  bone  at  the  apex  of  the  cone. 

The  single  flap,  or  a  short  anterior  and  long  posterior  flap,  is  performed 
as  follows  :  Stand  ujiou  the  right  side  of  the  limb  ;  grasp  the  thigh  with 
the  left  hand,  placing  the  fingers  and  thunii)  upon  ojiposite  points;  then 
apply  the  heel  of  a  long  amputating  knife  on  the  farther  side  of  the  limb 
at  the  ends  of  the  fingers,  and  draw  it  in  a  semicircular  direction  over  the 
limb  to  the  end  of  the  thumb;  with  this  single  sweep  divide  all  the  soft 
parts  down  the  bone  :  Avithout  entirely  removing  the  knife  withdraw  it 
sufficiently  to  enter  the  point  at  the  angle  of  the  wound,  and  transfix  the 
limb,  passing  under  the  bone,  and  emerging  at  the  angle  of  the  wound 


AMPUTATION. 


815 


on  tlie  opjjosite  side  ;  make  a  flap  of  the  requisite  length  from  tlie  poste- 
rior part  of  the  tiiigli.  Tlie  flaps  are  reti'aeted,  the  knife  earried  around 
the  bone,  and  the  saw  applied  at  the  highest  part  of  the  wound. 

Double  fl<ipx  are  formed  as  t()llows  :  Grasp  the  soft  parts  and  briiig 
them  forwai'd  ;  transfix  the  lind),  the  knife  grazing  tiie  upper  surface  of 

Fig.  o30.  Fio.  331. 


Circular  amputation 


DoubJe-tlap  amputation. 


the  bone,  and  make  a  short  anterior  flaji ;  reintroduce  the  knife,  and,  pass- 
ing under  the  bone,  make  a  posterior  flap  longer  than  the  anterior  to  com- 
pensate for  the  greater  retraction  ;  complete  the  operation  as  in  the  former 
method.  Flaps  may  also  be  made  from  the  sides  of  the  limb  by  intro- 
ducing the  knife  in  the  centre  of  the  limb  directly  down  to  the  bone,  on 
one  side  of  which  it  is  jiassed  to  the  oppo.site  side  of  the  limb,  and  a  flap  is 
then  formed  (Fig.  3-"51) ;  the  knife  is  reintroduced  and  a  flap  made  from 
the  opposite  side  ;  the  Haps  are  .strongly  retracted  and  the  bone  sawed. 

The   redaiujidar  flap  method   is  as  follows:  Make   a    longitudinal 
incision  on  either  side  of  the  limb  (Fig.  332),  in  length  equal  to  two- 

FiG.  332. 


Lino.s  of  incision  in  Teale's  amputation. 

thirds  of  the  circumference  of  the  limb  at  this  |)art ;  make  a  second 
incision  to  the  Ixme;  unite  the  lower  extremities  of  these  two  incisions; 
raise  this  quadrilateral  flap  from  the  bone  ;  make  a  third  incision  trans- 
versely down  to  the  bone,  forming  the  posterior  flaj) ;  raise  liotli  flajts 
and  firndy  retract  them;  saw  the  bone  at  the  junction  of  the  flaps,  and 
unite  the  flaps. 

Double  flnpx  of  the  infer/itments  and  circidur  incittion  of  the  muscles 
require  that  the  flaps  should  be  sufficient  to  meet  without  cftbrt,  should 
correspond  in  size,  and  shotdd  not  be  made  too  arched  ;  in  dividing  the 
muscles  the  knife,  uidcss  the  limb  be  of  unusual  dimensions,  should  be 
carried  down  to  the  bone  at  once,  and  this  can  only  he  done  by  the  appli- 
cation of  considerable  force,  great  care  being  taken  that  the  muscular 
mass  behind  the  bone  be  not  pushed  before  the  knife,  but  divided  without 
displacement  from  its  natural  relations  to  the  parts  around.     AMicn  the 


816 


OPERATIVE  SURGERY. 


liinl)  is  very  larnco  it  would  ho  well  to  divide  the  superficial  muscles  first, 
and  allow  tlicm  to  retract  hcthre  the  divisiou  of  tlie  remaiuder. 

The  periodeal  ft(ij)  is  most  pei'feet  when  made  as  follows :  Make  a 
circular  incision  directly  down  to  the  bone ;  saw  the  bono ;  while  an 
assistant  grasps  the  extremity  with  stout  forceps,  the  operator  raises  the 
periosteum,  beginning  at  the  extremity  of  the  cut  bone,  separating  its 

Fio.  333. 


Method  of  forming  periosteal  flaps. 


attachments  to  the  linea  aspera  with  the  knife ;  the  periosteotome  may 
be  used,  but  in  general  the  thumb-nails  will  be  found  most  efficient. 
The  periosteum,  thus  raised,  covers  the  central  part  of  the  flap  (Fig.  333), 
and  when  the  flap  is  brought  over  the  extremity  the  jjcriostcian  makes  a 
perfect  covering,  and  the  tissues  between  the  skin  and  periosteum,  being 
uninjured,  rapidly  unite. 

Fig.  334. 


A  stump  showing  mode  of  applying  sutures  and  drainage-tube.    A  drainage-tube 
is  sliovvn  at  the  left. 


The  bone  must  always  be  divided  as  follows :  The  jieriosteura 
having  been  I'aised  as  high  up  in  the  flap  as  possible,  first  a]iply  the  heel 
of  the  saw  and  draw  it  slowly  but  firmly  across  the  bone  to  make  a 
groove ;  then  move  it  rapidly  until  the  bone  is  nearly  divided,  when  it 
is  to  be  moved  more  slowly  to  avoid  splintering  the  last  connections ; 
with  the  bone  forceps  clip  off'  any  sharji  or  projecting  edges  and  l)evel 
the  end  of  the  bone  smoothly.     Where  there  is  a  single  bone  it  will  be 


AMPUTATION. 


817 


found  easier  to  apply  the  saw  nearly  iierpondicularly  on  tlie  side  opposite 
to  the  o])crator ;  where  there  are  two  Ixines  the  saw  shoiikl  be  first  and 
last  applied  to  the  larger  and  firmer  hone,  the  smaller  bone  being  eom- 
pletely  divided  while  the  saw  is  engaged  in  the  larger  bone. 

The  wound  must  be  closed  and  dressed  according  to  the  principles 
already  given.  The  application  of  hot  water  (1-30°  F.  to  140°  F.)  by 
rapid  douches  to  amputation  wounds  is  an  excellent  method  of  arresting 
hemorrhage  and  preparing  the  surfaces  for  pronijit  union.  The  hot 
water  must  not  be  allowed  to  remain  in  contact  with  the  limb.  The 
vessels  having  been  secured,  if  the  fibrous  sheaths  are  seen,  as  in  ampu- 
tations at  the  metacarpo-phalangcal  articulations,  close  them  with  two  or 
three  fine  sutures.  Then  close  the  wound  with  two  or  three  deep  and  sev- 
eral superficial  interrupted  sutures  (Fig.  334) ;  place  in  the  angles  of  the 
wound  proper  drainage-tubes  so  as  to  relieve  it  of  all  accumulating  fiuids  ; 
snjiport  the  jiarts  in  such  manner  l)y  sjilints,  or  slings,  or  pads,  that  it 
need  not  be  moved  in  dressing ;  apply  such  dressings  as  will  support  and 
protect  the  wound,  but  admit  of  easy  change. 


Fig.  335. 


I.    AMPUTATIONS    IN    THE    HAND. 

Operative  and  mechanical  surgery  unite  in  enforcing  the  rule  that 
in  the  hand  no  part  should  be  removed  that  can  be  saved ;  no  instru- 
ment-maker can  contrive  anything 
as  useful  as  a  finger.  A  great  vari- 
ety of  methods  of  operation  have 
been  devised  to  meet  the  emergen- 
cies which  arise  from  injuries  of 
the  hand  retpuring  amputation  (Fig. 
335). 

The  plialangefi  are  often  injured  in 
such  a  manner  as  to  compel  the  sur- 
geon to  perform  a  circular,  flap,  or 
some  modified  operation  to  secure 
the  requisite  covering;  but,  when  the 
parts  will  admit,  a  palmar  flap  is 
preferable,  as  the  cicatrix  is  by  this 
method  removed  to  the  dorsal  sur- 
face, the  stump  is  firm  and  well 
ada|)ted  for  use,  and  the  tactile  sen- 
sation is  less  impaired. 

The  anatomical  guides  to  the  ar- 
ticulations are  the  transverse  depres- 
sions (Fig.  336)  in  the  skin  on  the 
palmar  surface.  Between  the  bony 
l)rojcctions  at  the  side  'of  the  finger, 

at  the  articulation  of   the   second  and  -•'. ''isarticulntion  of  phalanx,  palmar  flap;  B, 

I  .     .       ,     ,                        ,               .  amputation  in  eontinuitv.  circular :  C,  lueta- 

tllirU    plialanges,  a    depression    marks  carpo-plialansical  fUsarticulation  ;  _D,  ampu- 

xi  „ •■•            i»    ,1           _,.      1    ,.  tation  of  a  nii-tac;iri)jil  bone  in  continuitv; 

tne     position    Ot     the     articulation;     a  JS.  ilisarticulatlnn  ..f  little  linger: /-.disloca 


tion  of  fifth  metacarpal ;  <»',  amputation  of 
wrist,  circular;  H,  amputation  of  wrist. 


jirominence  is  readily  detected  on  the 
dorsum  of  the  second  i)halanx  just 
in  front  of  its  articulation  with  the  distal  extremity  of  the  first  phalanx ; 

Vol.  I.— 52 


818 


OPERATIVE  SURGEnY. 


the  articulation  of  the  first  |)iialaii,\  with  liic  iiu'tacarpal  l)on('  is  ininu'- 
diatcly  bchiiul  the  bony  proiiiiiifiices  of  tlu'  proximal  extreiiiity  of  the 
first  phalanx.  The  transverse  depressions  in  the 
skin  on  the  palmar  surface  of  each  finger  are  three 
in  number,  and  have  the  follo\vin<i;  relation  to  the 
corresponding-  articulations,  conunencing  with  the 
extremities  of  the  fingers  held  in  an  extended  posi- 
tion :  The  first  dejiressiou  is  situated  about  a  line 

Fig.  337. 

Fig.  338. 


Guides  to  articu- 
lation. 


Plialanx  flexed. 


The  mode  of  holding  the  finger  during 
disarticulation  of  the  last  phalanx. 


and  a  half  above  the  articulation,  /  (Fig.  336),  between  the  third  and  sec- 
ond phalanges ;  the  second  depression  is  situated  exactly  over  the  articula- 


FiG.  339. 


Amputation  of  a  finger:  cutting  the  flaps  by  transfixion  (Erichsen) 


tion,  d  (Fig.  336),  between  the  second  and  first  ])halanges ;  the  third 
depression,  e  (Fig.  336),  situated  at  the  commissure  of  the  fingers,  is 
about  an  inch  below  the  articulation,  b  (Fig.  336),  of  the  first  phalanx 


AMPUTATION. 


819 


Fig.  340. 


with  the  metacarpal  bone.  When  the  finger  i.s  placed  in  a  state  of 
extreme  fiexiun  it  will  be  seen  (Fig.  337)  that  the  relations  of  the  artie- 
iilatit)n  ciiange,  and  hence  the  point  at  which  the  articulation  is  to  be 
souglit  will  depend  on  the  position  of  the  finger. 

The  palmar  flap  of  a  finger  is  made  tiius :  Pronate  tiie  hand  and 
reciuire  an  assistant  to  Iiold  apart  the  sound  fingers;  seize  the  phalanx 
witii  tiie  thumb  and  index  finger,  and  bend  it  to  an  angle  of  forty-five 
degrees;  recognize  the  line  of  tiie  joint  as  follows:  On  the  dorsal  sur- 
face there  is  a  well-marked  fold  in  the  skin,  and  the  joint  is  half  a  line 
below  it ;  or,  if  this  is  not  found,  recognize  the  dorsal  projection  formed 
bv  flexion,  and  cut  half  a  line  Ix'vond  it;  or  seek  the  termination  of  the 
j>almar  fi)ld,  and  find  the  joint  iuilf  a  line  below  it.  In  amputations 
tiin)Ugh  tlie  shaft  of  a  jihalanx  tlie  ])almar  flap  may  be  made  by  trans- 
fixion (Fig.  339).  Make  first  the  dorsal  incision,  then  make  a  palmar 
flap  of  ample  dimensions  (Fig.  338,  Treves). 

The  oval  method  at  the  articulations  is  as  follows :  Grasp  the  finger 
in  a  prone  position  on  its  palmar  and  dorsal  surfaces  by  the  fingers  and 
thumb  of  the  left  Iiand,  and  flex  to 
an  angle  of  forty-five  degrees  ;  make 
an  incision  iialf  an  inch  long  on  the 
dorsal  aspect  of  the  joint  a  quarter 
of  an  inch  above  it,  C  (Fig.  340), 
and  carry  it  then  across  tiie  palmar 
surface  to  the  opposite  side,  tiie  fingi'r 
iH'ing  fi)rcibly  extended  ;  tlience,  the 
finser  beintr  asain  flexed,  tiie  incision 
is  continued  upward  to  the  dorsum  ; 
dissect  the  borders  of  the  wound 
from  tiie  head  of  the  phalanx,  enter 
tiie  joint  on  its  dorsal  aspect,  divide 
the  extensor  tendons  and  lateral  lig- 
aments, increase  the  flexion,  wath  an 
eft"ort  to  luxate  the  joint,  which 
renders  tlie  flexor  tendons  easy  of 
division.  The  oval  amputation,  D 
(Fig.  340,  Treves),  wiiieli  is  designed 
to  ])lace  tlie  cicatrix  beyond  pressure, 
is  useful  (Faralieuf ). 

A  single  finger  may  be  removed 
at  the  metacarpo-phalangeal  articula- 
tion by  the  oval  method  (Fig.  340, 
Treves).  A  single  finger  and  its  meta- 
carpal hone  may  be  removed  by  ex- 
tending tlie  preceding  incision  (Fig. 
340,  Treves). 

The/our  fingers  nlay  be  removed 
at  a  single  operation.  The  distal 
extremities  of  the  metacarpal  liones 
are  not  all  on  the  same  line ;  those 
of  tlie  index  and  ring  fingers  are  nearly  on  a  level,  while  that  of  the 
middle  finger  is  about  half  a  line  lo\\er,  and  that  of  the  little  finger  is 


^,  disartioulation  by  single  external  flap:  S, 
ami)Utatii>n  by  lateral  flaps  ;  C,  disarticula- 
tion by  oval  or  raoket  incision;  D,  modified 
racket  incisiiiii  fur  imlcx  finger:  E,  circular 
niclhnd,  w  itli  \i'rtii'iil  <lorsal  cut:  F.  incision 
en  cnnipih'e;  G,  interuo-palTnar  flap  method 
for  little  finger :  H,  disarticulation  by  single 
palmar  flap;  /,  disarticulation  by  racket 
incision:  A',  amputation  of  the  fingers  with 
their  metacarpal  bones;  L,  circular  disartic- 
ulation at  the  wrist. 


820 


OPERATIVE  SURGERY. 


half  a  line  higher.  The  hand  being-  well  pronated,  grasp  the  four 
fingers  with  the  left  hand  and  flex  them  moderately  while  an  assistant 
supports  the  hand  and  retracts  the  skin  as  much  as  possible ;  with  a 

Fig.  341. 


Amputation  i)f  nil  the  fingers. 

straight  narrow  knife  make  a  curved  dorsal  incision,  a,  b,  e  (Fig.  341) 
%\ith  its  convexity  looking  downward,  fi'om  six  to  eight  lines  below  tlic 
heads  of  the  metacari)al  bones,  from  the  index  toward  the  little  finger 
if  the  left  hand,  and  in  the  opposite  direction  if  the  right ;  the  exten.sor 
tendons  being  exposed  by  the  retraction  of  the  integuments,  which  is 
assisted  by  a  few  strokes  of  the  knife,  open  each  of  the  metacarjio- 
phalangeal  articulations ;  divide  the  extensor  tendon  first,  then  the 
lateral,  and  finally  the  palmar  ligamentous  attachments ;  carry  the  knife 


Fig.  342. 


Fig.  344. 


Eesults  of  amputation  at  metacarpo-phalangeal  artie\ilation  in  middle,  index,  and  ring  fingers. 

through  the  articulations  to  the  jialmar  as]K'ct  of  the  phalanges,  and  cut 
outa  fia]>  limited  anteriorly  l)y  the  folds  in  the  skin  at  the  base  of  the 
fingers  on  their  palmar  surfaces. 

Bv  the  same  method  two  or  three  fingers  may  be  amputated,  the 
sound  fingers  being  held  aside ;  the  dorsal  flap  is  then  formed  by  the 


AMPUTATION. 


821 


Fig.  345. 


point  of  the  knife;  or  the  hand  may  be  held  in  the  supine  position  and 
the  flap  made  first  from  the  pahuar  surface.  The  appearance  of  the 
stump  is  improved  by  sloping  the  projecting  portion  of  each  knuckle 
with  cutting  pliers. 

The  results  of  these  amputations  are  excellent  both  as  regards  the 
usefulness  of  the  hand  and  its  appearance  (Figs.  342,  343,  344). 

The  thumb  may  be  amputated  at  its  phalangeal  or  metacarpal  articu- 
lation. The  first  is  performed  in  the 
.same  manner  as  that  of  the  fingers, 
but  the  removal  at  the  metacarpo- 
phalangeal articulation  reqiures  a 
large  flap,  owing  to  the  great  size  of 
the  head  of  the  metacarpal  bone. 
Make  an  incision  on  the  dorsal  aspect, 
convex  upward,  the  centre  being  a 
little  above  the  joint,  and  the  ex- 
tremities terminating  on  each  side  at 
the  end  of  the  palmar  transverse  fold  ; 
extend  the  thumb  and  make  a  palmar 
convex  incision,  uniting  the  extremi- 
ties of  the  first,  the  centre  extending 
midway  between  the  transverse  cuta- 
neous fold  alluded  to  and  tliat  mark- 
ing the  articulation  of  the  first  and 
second  phalanges  ;  open  the  joint  and. 
complete  the  disarticulation,  remov- 
ing the  sesamoid  bones,  D  (Fig.  341, 
Treves).  The  palmar  flap,  applied 
to  the  end  of  the  bone,  sin  mid  accu- 
rately fit  the  curved  incision  above. 
Or  the  flap  may  be  made  by  trans- 
fixion (Fig.  346). 

Tlie  appearance  of  the  hand  after 
amputation  of  the  thumb  is  good  ; 
the  power  of  grasping  is  lost,  but 
prehension  remains. 

A  single  vietacarpal  bone  is  re- 
moved by  an  incision  on  the  dorsal  aspect  corresponding  in  length  with 
the  portion  of  the  bone  to  be  removed.  Separate  the  soft  parts  cautiously 
from  the  bone,  the  knife  being  carried  parallel  with  its  long  axis  to 
avoid  wounding  the  palmar  arch  ;  having  made,  the  incisions  on  both 
sides,  pass  the  point  of  the  knife  under  the  bone,  so  as  to  appear  at  tiie 
opposite  side,  and  then,  by  carrying  it  fi)rward  in  contact  with  the  under 
surface  of  the  bone,  di.vide  the  soft  parts  at  one  section  :  if  the  operation 
is  of  either  the  third  or  fourth  metacarpal  bone,  the  section  should  be 
made  with  the  bone  forceps ;  if  of  the  metacarpal  bone  of  the  thumb, 
saw  it  perpendicularly  to  its  axis ;  if  of  the  index  finger,  make  a  section 
obliquely  from  without  inward,  tiie  hand  being  supine ;  if  of  the  little 
finger,  from  within  outward  (Fig.  347),  a,  the  soft  parts  being  withdrawn 
by  the  retractor,  b. 

Amputation  throiufh  the  four  metacarpal  bones  (Fig.  348)  is  made  as 


A,  disartieulatiou  by  special  externo-palmar 
flap ;  B,  disarticulation  by  lateral  flaps ;  C, 
am)iutatiiin  liv  unequal  dorso-palmar  flaps; 
J),  disarticulation  by  oblique  palmar  flap;  E, 
disarticulation  of  the  rins  tinker  with  its 
mctac  ar|>al  bi.uc  bv  racket  incision  ;  F,  same 
operation  upon  tlic  little  liiiKer :  G,  Dubru- 
eil's  disarticulation  at  the  wrist. 


822 


OPERATIVE  SURGERY. 


follows :  Make  a  palmar  flap  as  in  disarticulation  of  all  the  fingers,  and 
a  similar  incision  on  the  dorsum  ;  jiass  the  i^nife  into  the  interosseous 
spaces,  separate  the  muscular  attachments,  and  divide  the  periosteum ; 

Fig.  34G. 


Amputation  of  the  right  thumb  by  transfixion :  cutting  the  anterior  flap. 


apjily  a  five-tailed  retractor,  a  (Fig.  348),  and  saw  the  hones  with  a  meta- 
carpid  saw,  or  the  palmar  flap  may  be  convex  forward  and  the  dorsal 
flap  concave,  k  (Fig.  340). 


Fig.  34 


Amputation  of  a  single  metacarpal  bone. 

Disarticulation  of  the  thumb  irilh  flic  first  metacarpal  bone  is  performed 
as  follows :  The  joint  is  of  a  mixed  character  between  arthrodial  and 
ginglymoid  ;  on  its  dor.sal  surface  it  is  almost  subcutaneous,  but  covered 
with  thick  muscle  on  its  palmar  aspect ;  the  radial  artery  passes  around 


AMPUTATION. 


823 


its  ulnar  side ;   it  has  a  loose  capsule  ;    the  joint  runs  in    an  oblique 
direction,  in  a  line  drawn   from  its  external  side  to  the  root  of  the 


Fig.  349. 


Amputation  of  aU  the  metacarpal  bones. 

little  finger;  its  position  is  easily  deterniined  liy  the  projection  of  the  en- 
largement of  the  head  of  the  bone  on  pressing  the  thumb  into  the  palm  ; 
it  lies  ;ui  inch  and  a  quarter  below  the  styloid 
process  of  the  radius.  Hold  the  liand  in  a 
position  I)etween  supination  and  pmuation ; 
make  an  incision  along  tiie  dorsal  surface  of 
the  metacarpal  bone  of  the  thumb,  connnen- 
cing  six  lines  above  its  articulation  (Fig.  349, 
Treves)  with  the  trapezium,  and  extending 
througli  all  the  tissues  down  to  the  bone,  to 
the  inner  side  of  tiie  liead  of  the  first  ])iialanx 
of  the  tiuunb,  on  a  level  with  the  conunissure 
between  the  thumb  and  index  linger  ;  carrying 
the  hand  to  pronation,  continue  the  incision 
around  the  palmar  surface  of  the  phalanx  to 
its  outside,  and  thence  to  the  dorsum  of  the 
metacarpal  bone  to  join  the  first  incision  al)out 
its  middle ;  detacli  ti'.e  nuiscles  and  integu- 
ments from  either  side  of  the  bone,  and  open 
the  articulation  from  its  dorsal  aspect  (Fig. 
350) ;  then,  endeavoring  to  dislocate  the  bone 
outward,  complete  the  division  of  its  rcmain- 
ijig  attachments. 

JJi-sarficuhttion  of  the  ficcoricl  metacarpal 
bone  is  rendered  especially  difficult  on  ac- 
count of  the  prolongation  of  that  jjart  of  its  head  that  is  in  relation 
with  tile  trapezoid,  os  magnum,  and  third  metacarpal.  The  hand  held 
in  ])ronation,  tiie  thumb  and  fingers  separated,  make  an  incision,  com- 
mencing about  half  an  inch  in  front  of  the  styloid  ])roccss  of  tlie  radius, 
but  on  a  line  witli  the  .second  metacarpal  bone,  d  (Fig.  350),  and  con- 
tinue to  tlie  internal  side  of  the  base  of  the  first  phalanx,  o  ;  now  carry 


Disarticulation  of  the  thumb  with 
its  metacarpal  bone  by  a  racket 
incision. 


824 


OPERATIVE  SURGERY. 


it  around  the  palmar  surface  in  the  cutaneous  fold — represented  on  the 
dorsum  by  the  line  b,  c — to  the  point  c;  and  thence  to  jioint  of  com- 
mencement, (/ ;  dissect  the  soft  parts  by  keeping  the  knife  close  to  the 
bone,  tlu'  wound  being  held  apart;  carry  the  knife  up  along  the  internal 
side  of  the  bone  to  the  union  of  the  Pj,.  351 

two  metacarpal   bones,  and,  turning 
its  edges  inward,  divide   the   inter- 

FiG.  350.  «  — 


Line  of  incision  for  removal  of  second 
metacarpal  bone. 


Amputation  of  tirst  metacarpal  bone. 


osseous  ligament,  and  in  the  same  manner  enter  the  knife  into  the 
articulation  of  the  metacarpal  bone  with  tiie  trajiezius ;  the  anterior  and 
posterior  ligaments  are  next  divided,  the  bone  di.^located,  and  the  knife, 
entered  flatwise  and  horizontally  under  the  ujijier  part  of  the  bone  a  and 
6  (Fig.  351),  is  carried  downward,  completing  the  operation  ;  care  should 
be  taken  in  dividing  the  ligaments  not  to  penetrate  any  adjoining  articu- 
lar cavity. 

Dimrticiilation  of  the  fifth  metacarpal  bone  may  be  performed  by  two 
methods :  The  unciform  receives  the  fifth  metacarpal  lione  upon  a  sur- 
face concave  from  behind  forward  ;  the  line  of  articulation,  if  prolonged, 
would  fall  upon  the  middle  of  the  second  metacarpal  bone.  (1)  Pronate 
the  hand  and  commence  an  incision  one  line  above  the  articulation  F 
(Fig.  345,  Treves),  and  carry  it  along  the  dorsum  to  the  commissure, 
then  under  the  finger,  along  the  fold  of  the  integument,  to  the  opposite 
side,  and  tlience  back  to  the  point  of  dejiarturc ;  dissect  the  soft 
parts  from  the  bone  and  di.sarticulate.  (2)  The  hand  being  held  in  a 
state  of  forced  pronation,  commence  at  the  carpo-metacarpal  joint  with 
a  slight  lateral  incision,  and  carry  it  down  in  a  straight  line  to  the  inner 
border  of  the  first  phalanx  of  the  little  finger  until  it  meets  the  depres- 
sion at  the  base  of  the  little  finger  on  its  palmar  surface  ;  then  continue 
it  around  the  base  of  the  finger,  following  this  depression  exactly,  and, 
lifting  the  little  finger,  continue  the  incision  around  to  its  inside  and 
upward  to  join  the  first  portion  about  opposite  to  the  centre  of  the  meta- 
carpal bone ;  detach  the  integuments  and  muscles  from  the  bone,  and 
divide  its  articular  connection  with  the  point  of  the  bistoury  in  the 
manner  already  described. 

Disarticulation  of  a  mdaearpal  bone  is  as  follows  (Fig.  345)  :  Make  a 
transverse  incision,  E,  a  little  in  front  of  the  articulation,  another  upon 
the  dorsum  of  the  metacarpal  bone ;  the  disarticulation  is  then  readily 
effected. 


AMPUTATION. 


825 


Disarfiindntini)  of  the  metacarpal  honeH  of  the  foar  fingers  \s  performed 
thus :  Hold  the  hand  in  the  position  of  forced  su])ination  and  introduce, 
opposite  the  articulation  of  the  fifth  metacarpal  \\itli  the  unciform  boue, 


Fig.  352. 


Fia.  3.53. 


Disarticulation  of  metacarpal  bones  of  four  fingers. 

a  small,  straight  knife  Itetween  the  bones  and  the  soft  parts,  carrying  it 
a  little  below  the  projections  formed  by  the  unciform  and  the  trapezium, 
so  as  to  bring  out  its  point  below  the  thumb  ;  carry  the  blade  of  the 


Fig.  3.'54. 


Fig.  355. 


Amputation  at  the  wrist  by  long  palmar  flap 
^Eriehsen). 


Same  disarticulation  by  external  flap. 


knife  along  the  jialniar  surfaces  of  the  metacarpal  bones,  and  cut  out  a 
large  flap  of  an  elliptical  outline,  a,  h,  <•  (Fig.  .352) ;  turn  the  hand  to  a 
prone  position  and  make  a  semicircular  incision  across  its  back,  two- 


82G  OPERATIVE  SUIIGERY. 

tliii-(ls  of  an  inch  below  the  lino  of  the  articulations,  and,  carrying  the 
knife  through  the  tissues  connecting  the  thumb  with  the  index  finger, 
«,  6,  c  (Fig.  353),  join  the  first  incision  ;  while  an  assistant  is  drawing  the 
intcgunients  U]n\!ir<l  lidhl  the  metacarpus  in  tlie  li'ft  hiind,  disarticulate 
friim  tlu'  front,  conuncncing  with  tlie  metacarpal  bone  of  tlic  index  or 
little  finger,  according  as  the  operation  is  upon  the  rigiit  or  h'ft  hand. 

Dharticidatlon  at  the  ivrist-joint  gives  the  best  results  when  a 
fla])  is  taken  from  the  palmar  surface  of  the  hand.  To  determine  the 
articulation,  (1)  strongly  bend  the  hand  backward ;  the  summit  of  the 
angle  formed  by  it  M-ith  the  forearm  indicates  the  radio-carjial  articula- 
tion ;  (2)  feel  in  front  of  the  transverse  line  of  the  ra(Hus ;  the  joint  is 
one  line  below  it,  and  two-thirds  of  an  incli  above  the  I'rcase  in  the  skin 
tliat  separates  the  palm  of  the  hand  from  the  forearm  ;  (3)  determine  the 
summit  of  the  styloid  processes  and  draw  a  transverse  line  between  them; 
this  line  will  be  two  lines  and  a  lialf  below  the  joint. 

A  tiUu/Ie  pahiutr  flap  is  made  as  follows  :  An  assistant  holds  the  hand 
in  a  supine  position  ;  grasp  the  extremity  in  the  palm  of  the  left  hand, 
jilacing  the  thuml)  and  forefinger  on  tiie  extremities  of  the  styloid  pro- 
cesses ;  make  a  semicircular  flap  from  tiie  palm  (Fig.  354),  extending 
from  just  below  the  processes  ;  dissect  the  flap  and  turn  it  back,  make 
a  small  flap  at  the  dorsum,  and  divide  the  tendons,  the  radio-carpal  and 
lateral  ligaments.  An  external  flaji  (Dubrueil)  may  be  made  wliich  will 
give  a  good  covering  (Fig.  355,  Chalot). 

AMPUTATION    THROUGH    THE    FOREARM. 

It  is  important  to  preserve  as  long  a  stump  as  possible  of  the  forearm 
for  various  occupations  and  for  tiie  application  of  apparatus.  It  is  better, 
therefore,  to  amputate  near  to  than  at  the  elbo\v -joint,  for  the  smallest 
movable  part  of  tiie  forearm  may  be  useful.  The  arteries  are  the  radial, 
ulnar,  and  anterior  and  posterior  interosseous;  two  bones  of  diiierent 
diameters,  at  different  parts  of  the  limb,  are  to  be  divided. 

Semicircular  skin-flaps  and  circular  of  the  muscles  is  the  best  method 
of  amputation  in  any  part  of  the  forearm.  The  skin  is  usually  too  thin 
for  one  long  skin-flap,  and  there  are  too  many  tendons  fiir  the  rectangular 
flap.  Operate  thus  :  The  arm  being  held  with  the  hand  supine,  so  as  to 
render  the  bones  parallel,  cut  from  the  anterior  and  posterior  surfaces 
semicircular  flaps  of  suitable  length,  including  the  tissues  above  the  mus- 
cles ;  turn  these  flaps  backward  and  with  a  long  knife  divide  the  tissues 
to  the  bone  (Fig.  356) ;  saw  the  two  bones  at  the  same  time. 

Fig.  356. 


Vminitati         II      i        nin  1  v  mixed  method  (Bryant). 

The^«;j  method  maybe  single  or  double.     The  arm  being  held  in  the 
position  between  pronation  and  supination,  with  the  thumb  uppermost. 


AMPUTATION. 


827 


SO  tliat  the  radius  and  ulna  are  in  one  line,  insert  a  sharp-pointed  knife 
close  to  the  inner  edge  of  the  radius  and  bring  it  out  opposite  at  tiie  edge 
of  tiie  ulna :  if  a  single  flap  is  to  be  made,  it  must  be  taken  from  the 
anterior  face,  and  be  long  enough  to  completely  cover  the  stump ;  if  a 
double  flaji  is  preferred,  make  an  anterior  flap  the  length  of  half  the 
diameter  of  the  arm  and  a  ])osteri()r  flap  of  equal  length  ;  turn  hack  the 
flaps,  divide  the  tendinous  nuiscular  or  interosseous  flbres  not  cut  through, 
and  divide  the  bones  as  in  the  circular  operation. 


Fig.  357. 


AMPUTATION'    AT   THE    ELBOW-.K  )IXT. 

Amputation  at  the  elbow-joint  is  to  be  preferred  to  amputation 
through  the  arm  if  no  artificial  arm  is  to  be  aj)])lied,  as  the  stump  is 
broad  and  firm  and  can  be  made  more  useful.  Several  methods  are 
adapted  for  this  articulation  (Fig.  357).  The  cir- 
cular and  single  anterior  flap  methods  are  generally 
to  be  preferred. 

The  exact  position  of  the  joint  is  determined 
by  careful  attention  to  the  anatomical  relations  of 
the  following  osseous  prominences  about  the  joint: 
the  epicondyles,  or  the  most  prominent  points  on 
the  condyles  of  the  os  brachii  are  recognized,  the 
internal  more  readily  than  the  external  ;  also  the 
olecranon,  c  (Fig.  359) ;  a  line  drawn  through  the 
lower  j)oints  is,  on  the  outside,  a  quarter  of  an  inch 
above  the  interarticular  line,  b  (Fig.  358),  and  on 


Fig.  358. 


Fig.  359. 


Amputation  at  the  elbow- 
joint:  .1,  antiTior  flap:  i?, 
external  flap ;  C.  circular 
method. 


Anatomical  points  about  the  elbow-joint. 


the  inside  three-quarters  of  an  inch,  e  ;  the  articulation  of  the  radius  and 
humerus  is  transverse,  that  of  the  ulna  irregular,  and  owing  to  its  pro- 
jections must  be  entered  e.xternally.  Two  facts  appear  :  first,  that  the 
articular  interline  is  very  oblique  from  without  inward  and  from  above 
tlownward  ;  second,  that  it  is  very  mucii  l)elow  the  tuberosities  of  the 
humerus.  If,  then,  in  cutting  the  anterior  flap  its  base  is  extended  up  to 
the  level  of  these  tuberosities,  it  will  almost  always  he  too  short  to  cover 
the  bone,  which  will  project,  especially  on  the  inside  and  downward ; 
therefore  enter  the  knife  one  inch  below  the  middle  projection  of  the 
epitrochlca  to  bring  it  out  half  an  inch  below  the  prcjectiou  of  the 
epicoudyle. 


828 


OPERATIVE  SURGERY. 


The  circular  method  is  as  follows,  ('  (Fig.  357) :  The  arm  being  held 
in  a  sui)ine  position,  make  a  circular  incision  through  the  skin  only, 
three  or  four  inches  according  to  the  size  of  the  limb  below  the  joint ; 
dissect  uj)  the  integuments  to  the  joint  and  reflect  backward,  a,  h  (Fig. 


Fig.  3CjO. 


Fig.  3G1. 


Circular  amputation  at  the  elbow. 


Flap  amputation  at  the  elbow. 


360) ;  divide  the  muscles  in  front  and  the  ligaments,  enter  the  joint,  and 
complete  the  disarticulation  by  dividing  the  triceps  or  .sawing  off  the 
olecranon  ;  the  brachial  artery  is  divided  above  its  bifurcation. 

The  niiif/Zc  (inferior  fiiip  is  made  thus:  Supinatc  and  slightly  flex  the 
limb,  and  make  a  flap  from  the  .soft  parts  of  the  ji>int ;  insert  a  straight 
knife  an  inch  below  the  internal  condyle,  traverse  the  limb  close  to  the 
ulna,  until  it  appears  one  and  three-quarters  inches  below  the  external 
condyle,  to  allow  for  retraction  of  muscles  arising  from  the  humerus ; 
(tut  an  inferior  flap  a,  b,  c  (Fig.  361),  about  three  inches  in  length  ;  retract 
tins  flap,  and  jniss  the  knife  l)ehind  the  liml),  and  enter  the  heel  on  the 
outside  between  the  radius  and  os  brachii,  and  extend  the  incision  ; 
draw  it  across  the  back  part  of  the  joint,  dividing  all  the  tissues  to  the 
internal  angle  of  the  wound ;  divide  the  anterior  ligament  and  the  lateral 
ligaments,  luxate  the  bones  forward,  cut  the  triceps,  and  complete  the 
operation. 

An  external  flap,  B  (Fig.  357),  maybe  preferred  in  some  cases  of 
accident :  Make  the  flap  by  transfixing  the  limb  upon  the  outside ;  insert 
the  point  of  the  knife  just  ■s^'ithin  the  head  of  the  radius ;  traverse  the 
neck,  cutting  out  a  larger  external  flap ;  a  second  flap  is  made  from  the 
inside  of  the  arm  by  cutting  from  without  inward  and  from  below 
U])ward,  the  soft  tissues  immediately  covering  the  joint  are  then  divided 
and  disarticulation  completed. 


AMPUTATION    OF   THE    AEM. 

Amputation  of  the  arm  may  be  performed  at  any  point,  but,  as  a 
rule,  as  little  should  be  sacrificed  as  possible.  Owing  to  its  uniform 
size  and  single  central  lionc  any  of  the  different  methods  may  be  applied, 
but  the  periosteum  should  be  raised  for  a  covering  to  the  l)onc.  There 
are  two  elliptical  methods:  one  on  the  posterior  and  the  other  on  the 
anterior  face  of  the  limb,  the  highest  point  in  the  former' being  the 
olecranon,  and  of  the  latter  the  bend  of  the  elbow.     The  former  is  to  be 


AMPUTATION. 


829 


preferred  (Fig.  362),  as  it  furnishes  an  ample  covering  and  posterior 
cicatrix. 

Tlie  circular  operation  gives  a  good  stump,  and  is  as  follows  :  Place 
the  arm  at  right  angles  to  the  body ;  standing  on  the  rigiit  side  of  the 
limb,  make  a  circular  incision  through  the  integuments ;  roll  the  flap  one 
and  a  half  to  t\\-o  inches,  according  to  the  size  of  the  limb  ;  make  a  second 
incision  at  the  margin  of  the  retracted  skin  ;  divide  and  retract  the 
superficial  muscles,  and  make  a  third  incision  down  to  tlie  bone ;  raise 
the  periosteum  an  inch  and  sa\\'  the  bone ;  the  brachial  artery  lies  on  the 
inside,  between  the  biceps  and  internal  portion  of  the  triceps  muscles. 

The  flap  operation,  may  be  single,  and  may  be  made  at  any  point  pre- 
senting on  one  surface  a  suflflcient  amount  of  tissues ;  two  flaps  of  equal 
size  are  preferable  generally  ;  they  are  anterior  and  posterior ;  the  arm 
being  carried  at  a  right  angle  with  the  body,  grasp 
Fig.  362.  with  the  left  hand  the  tissues  on  the  anterior  or 

lateral  part  of  the  arm,  and,  passing  the  knife  down 
to  the  bone,  carry  it  over  to  the  opposite  side,  and 
cut  out  a  flap  in  length  three-fourths  the  diameter 
of  the  limb  (Fig.  363) ;  insert  the  knife  close  to  the 

Fig.  363. 


Disarticulation  at  liie  elbow-joint 
by  tlie  posterior  ellipse  method. 


Amputation  of  arm  by  flap  operation  (T.  Bryant). 


bone  on  the  opposite  side  and  make  a  similar  flap ;  firmly  retract  the 
flaps,  divide  the  tissues  covering  the  bone,  and  saw  the  bone  at  the 
highest  point  betM'een  the  flaps. 


AMPUTATION   AT   THE   SHOULDER-JOINT. 

The  shouhler-Joint  is  arthrodial ;  the  articular  head  of  the  os  brachii 
is  very  broad,  and  articulates  by  scarcely  one-third  with  the  siiallow 
glenoid  cavity  of  the  scapula  ;  it  is  connected,  too,  by  a  loose  capsular 
ligament ;  tiie  joint  is  strengtlicned  by  tiie  long  head  of  the  biceps  and 
the  muscles  arising  fronr  the  scapula  and  inserted  in  the  vicinity  of  the 
joint ;  the  joint  is  protected  above  by  the  extremity  of  the  clavicle  and 
the  acromion  process. 

It  is  of  tlie  utmost  importance  to  prevent  hemorrhage  during  the 
operation,  and  to  effect  this  object  there  are  now  entirely  reliable  means. 


830 


OPERATIVE  SURGERY. 


Pressure  upon  the  sutx^lavian  with  a  key  and  seizing'  tlie  flap  contain- 
ing the  axillary  artery  are  unsafe  measures,  and  should  be  resorted  to 
only  in  the  absence  of  the  proper  ajjjjliances.  The  elastic  bandage  may 
be  applied  (Fig.  360)  so  as  to  render  Itleeding  im]X)ssil)le  either  from 
the  axillary  artery  or  smaller  vessels.  Pins  may  be  employed,  as  fol- 
lows:  Select  two  pins,  sharp-])oiiit('d  and  cylindrical,  eleven  inches  long 
and  one-fourth  of  an  inch  in  diameter  near  the  lica<l;  introduce  the  first 
pin  through  the  middle  of  the  anterior  axillary  fold,  a  little  nearer  to 
the  body  than  the  transverse  centre  of  the  transverse  fold  made  by  the 
pectoralis  major;  the  place  of  emergence  should  bean  inch  within  the  tip 
of  the  acromion  ;  the  jioint  of  the  i)in  when  in  position  should  I)e  ])ro- 
tected  by  a  sterilized  cork.  The  second  pin  should  Ite  introihiccd  at  a 
corresponding  point  through  the  posterior  axillary  fold,  the  tendon  of 
the  latissimus  dorsi,  emerging  an  inch  within  the  tip  of  the  acromion. 
A  piece  of  black-rubber  tubing,  half  an  inch  in  diameter,  should  now  be 
wound  tightly  around  the  limb  above  the  pins,  so  as  to  completely  inter- 
rupt all  circulation.  The  vessels  should  be  ligated  as  quickly  as  possible, 
and  the  tulting  and  pins  removed.  Ligation  of  the  vessels  in  the  space 
between  the  deltoid  and  the  great  pectoral  has  been  performed,  with  good 
results,  before  amputation. 

The  oval  method  is  well  adapted  to  cases  of  fracture  near  the  joint. 
Make  a  vertical  incision  from  the  end  of  the  acromion  process  over  the 
head  of  the  humerus  down  to  the  bone,  A  (Fig.  364) ;  then  two  oblique 


Fig.  365. 


Disarticulation  at  the  slioulilcr;  .1,  oval 
method ;  B,  metliod  by  deltoid  flap. 


Disarticulation  at  the  .shoulder ; 
Spence's  method. 


incisions  starting  from  the  lower  end  of  the  vertical,  one  on  the  anterior, 
the  other  on  the  posterior,  aspect  of  the  joint,  carrying  them  through  the 
tissues  composing  the  anterior  and  posterior  walls  of  the  axilla  to  the 
lower  border  of  each,  and  dividing  their  attachments  to  the  humerus. 
Push  the  edges  of  the  wound  on  cither  side  to  expose  the  joint,  and  open 
it,  making  traction  on  the  Ixme  to  put  its  ligament  on  the  stretch  ;  luxate 
the  head  of  the  bone,  pass  the  knife  behind  it,  and  finish  the  operation  by 
cutting  directly  through  the  tissues  in  the  axilla  which  intervene  between 


AMPUTATIOX. 


831 


the  extremities  of  the  incisions  alreadv  nuidc,  recollecting  that  they  con- 
tain the  artery,  which  requires  to  lie  compressed  by  an  assistant.     The 


Fig.  3(36. 


Esmarch's  tournuiiiet  applied  to  shouMer. 


wonnd  which  results  from  this  operation  is  almost  perfectly  oval   iu 
shape.      Or,  the  head  of  the  bone  may  be  dissected  from  its  cavity, 


Fig.  367 


Amputation  at  shoulder,  modifled  oval  (Spence). 


M-ith  the  knife    held  vertically,  first  upon  one  side  and  then  upon  the 
other,  and  the  operation  completed  by  dividing  the  axillary  portion. 


m-1 


OPERA  TI VE  S  UR  GER  Y. 


The  modified  ocal  opcrafion  (Fi<j.  367)  is  adapted  to  gniislHit  wounds. 
It  is  as  follows  :  Slightly  ahduct  the  arm  and  rotate  the  humerus  out- 
ward ;  commence  an  incision  just  external  to  the  coracoid  process,  and 
carry  it  doM'n  through  the  chivieular  filjres  of  the  deltoid  and  pectoralis 
major  muscles  to  the  humeral  attachments  of  the  latter  musc-le,  which 
must  be  divided  ;  then  carry  the  incision  across  and  through  the  lower 
fibres  of  the  deltoid  toward,  but  not  through,  the  j)osterior  l)order  of  the 
axilla;  next  carry  an  incision  through  the  skin  and  fat  only  from  the 
point  where  the  straight  incision  terminated,  across  the  inside  of  the  arm, 
to  meet  the  incision  at  the  outer  part.  If  the  fibres  of  the  deltoid  have 
been  thoroughly  divided,  the  flap,  together  with  tlie  jjosterior  circumflex 
artery,  can  be  easily  separated  by  the  point  of  the  finger  from  the  Ijone 
and  joint,  and  drawn  ujiward  and  backward,  so  as  to  expose  the  liead  and 
tuberosities.  Now  divide  the  tendinous  insertions  of  the  capsular  mus- 
cles, the  long  head  of  the  biceps,  and  the  capsule,  and  disarticulate  and 
divide  the  remaining  attachment  (Fig.  3fi7). 

The  singJe-jiap  method  may  be  ftjllowed  \\  lien  there  is  no  fracture,  B 
(Fig.  364) :  the  arm  being  held  away  from  the  trunk,  grasp  the  deltoid 
in  its  entire  length  and  thickness  in  the  left  hand,  and  with  tlie  riglit 
pass  a  double-edged  knife  through  its  base,  under  the  acromion,  and, 
grazing  the  surface  of  the  Juimcrus,  cut  an  external  and  superior  flap 
of  sufficient  extent ;  an  assistant  raises  it ;  then,  by  approaching  the  arm 
to  the  body,  expose  the  tendons  of  the  muscles  inserted  into  the  head  of 
the  humerus  and  cut  them  ;  grasping  the  arm  with  the  left  hand,  dis- 
locate the  head  of  the  Iwne  outward  ;  pass  the  knife  beliind  it  and  incise 
the  soft  parts,  while  an  assistant  seizes  the  flap  in  such  a  manner  as  to 
prevent  hemorrhage  from  the  divided  axillary  artery,  and,  if  the  tissues 
are  hardened,  taking  care  not  to  allow  air  to  enter  the  veins. 

The  double-jieip  is  as  follows  :  The  arm  is  kept  close  to  the  trunk,  the 
head  of  the  humerus  being  pusheil  U])ward  and  outward  as  much  as  pos- 
sible ;  recognize  the  exact  position  of  the  acromion  and  coracoid  pro- 
cesses ;  on  the  left  shoulder  enter  the 
point  of  a  long  knife  almost  parallel 
Avith  the  humerus  at  the  outer  side  of 
the  posterior  border  of  the  axilla,  in 
front  of  the  tendons  of  the  latissimus 
dorsi  and  teres  major  muscles,  c  (Fig. 
368).  As  the  knife  passes  in  the  plane 
of  its  blade  it  should  form  an  angle  of 
thirty-five  degrees  with  the  axis  of  the 
shoulder,  and  its  point  should  graze  the 
])osterior  and  external  surface  of  the 
humerus  until  it  reaches  the  luider  sur- 
face of  the  acromion  ;  at  this  point  the 
handle  of  the  knife  should  be  raised 
and  its  point  lowered,  so  that  it  is 
brought  out  beloAV  and  in  front  of  the 
the  clavicle,  u,  in  the  triangular  space 
between  the  acromion  and  coracoid  pro- 
cesses, which  is  bounded  posteriorly  by  the  clavicle.  Make  the  knife 
cut  its  way  outward  around  the  head  of  the  humerus,  h,  and  as  soon  as 


Fig 


Duublo-flap*  amputation  at  shoulder. 


AMPUTATION. 


833 


it  becomes  disengaged  from  henoath  the  aeroinion  process  carry  the  arm 
away  from  the  trunk ;  now  grasp  tlie  deltoid  muscle  with  the  left  hand, 
raising  it  as  much  as  possible  from  the  bone,  and  carry  the  knife  directly 
downward,  grazing  the  bone,  and  cut  out  a  semicircular  flap  about  three 
inches  in  length.  In  making  this  flap  the  upper  part  of  the  capsvde  of 
the  joint  should  be  divided  as  well  as  the  tendons  of  the  latissimus 
dorsi,  teres  majt)r  and  minor,  and  part  of  the  deltoid ;  raise;  the  head  of 
the  humerus  from  the  glenoid  cavity,  pass  tiic  blade  of  the  knife  behind 
it,  and  carry  it  downward  and  forward,  grazing  the  humerus,  to  cut  out 
the  internal  flap,  and  at  this  moment  the  axillary  artery  should  be  com- 
pressed by  an  assistant. 

Amputntion  of  the  ami  and  scapu/a  may  be  performed  for  severe 
injuries  and  malignant  growths.  Treves-Berger's  operation  is  as  fol- 
lows:  Place  the  patient  on  the  back,  the  shoulders  raised,  and  make  an 
incision  along  the  clavicle  down  to  the  bone,  commencing  at  the  external 
border  of  the  sterno-mastoitl  and  ending  just  beyond  the  acromio-clavic- 
ular  articulation  (Fig.  369).     The  periosteum  being  separated  at  the 

Fig.  .Sf)9. 


Interscapulo-thoraeic  amputatiou. 

inner  extremity  of  the  wound,  pass  a  blunt  hook  carefully  around  the 
bone  at  this  point  and  divide  it,  either  with  the  chain  or  the  keyhole 
Siiw  ;  now  separate  the  periosteum  from  tiic  outer  portion  of  the  clavicle, 
and  saw  the  bone  again  at  the  junction  of  the  middle  and  outer  thirds; 
remove  this  middle  portion  of  the  clavicle. 

The  subclavius  muscle  is  next  turned  outw^ard  so  as  to  expose  the 
vessel.s,  and  double  ligatures  are  applied,  first  to  the  artery,  and  then  to 
the  vein,  and  the  vessels  are  divided  between  these  ligatures.  The  patient 
is  now  ])laccd  on  the  edge  of  the  tai)le  on  a  hard  cushion  ;  the  scapular 
region  is  free  ;  an  assi  taut  draws  the  limb  away  from  the  body,  and 
the  surgeon  takes  a  position  on  the  inner  side  of  the  limb.  Commence 
an  incision  at  the  centre  of  the  clavicular  incision  ;  curve  it  downward 
and  outward,  passing  just  outside  of  the  coracoid  process,  along  the 
deltoid  muscle,  ])arallel  to,  but  to  the  outer  side  of,  the  groove  be- 
tween that  muscle  and  tlie  ])ectoralis  major;  the  incision  should  now 
Vol.  I.— 53 


834 


OP  EH  ,1 TI VE  S  UR  GER  Y. 


cross  tlie  lower  margin  of  tli(>  pcctoralis  major  and  pass  transversely 
across  upon  the  axillary  surface  of  the  arm  to  the  lower  margin  of  the 
tendons  of  the  latissimus  dorsi  and  teres  major,  and,  while  the  arm  is 
raised,  be  continued  downward  and  inward  to  the  posterior  surface  of 
tiie  inferior  angle  of  the  scapula,  along  the  groove  between  the  vertebral 
border  of  the  scapula  and  the  mass  of  muscle  composed  of  the  U-xas 
major  and  the  latissimus  dorsi;  dissect  up  this  flap,  dividing  the  pcc- 
toralis major  where  it  is  becoming  tendinous,  and  the  minor  at  its  inser- 
tion into  the  coracoid  process ;  divide  the  brachial  plexus  close  to  the 
first  rib,  also  all  other  connections,  thus  freely  opening  the  axilla.  The 
arm  is  now  carried  across  the  chest  and  the  scapular  region  well  exposed  ; 
the  operator  takes  his  position  on  the  outside  of  tiie  extremity,  and 
makes  an  incision  from  the  outer  end  of  the  clavicular  incision  back- 
Mard  directly  over  the  spine  of  the  scapula  to  the  termination  of  tile 
anterior  flap  at  the  inferior  angle  of  the  scapula ;  the  attachments  of  the 
trapezius  to  the  clavicle  and  scapula  are  divided,  then  the  omo-hyoid, 
levator  anguli  scapuhe,  riiomboidcus  minor  and  ma_joi',  and  the  serratus 
magnus  ;  sever  the  remaining  connections  while 
Fifi.  370.  an  assistant  moves  the  limb  so  as  to  expose  at- 

tachments. 

Amputations  of  the  arm,  scapula,  and  clavicle 
liave  been  performed  for  malignant  diseases  by 
extension  of  this  method. 


AMPUTATION    OF    THE    FOOT. 

In  all  amputations  of  the  lower  extremity  the 
surgeon  should  l)e  governed  in  the  selection  of  the 
point  of  o])eration  and  the  method  to  be  adopted 
5r"~^C  (1)  by  the  mortality  of  the  operation  in  question; 
(2)  by  the  ada])tability  of  the  stump  to  the  most 
serviceable  artificial  limb  for  locomotion. 

Amputation  of  the  phahtnycs  in  the  continuity 
or  contiguity  is  jjerformed  by  the  same  rules  as 
have  been  given  for  similar  amputations  of  the 
fingers,  a  flap  being  generally  formed  from  the 
plantar  surface. 

Disdiiicalafion  of  single  toes  must  be  under- 
taken with  due  regard  to  the  following  facts : 
Surgical  guide  to  anatomy  of  The  extremity  of  the  first  metatarsal  bone  is 
footM.  cuboid  bone  t^Bj^arj  large,  and  requires  a  very  liberal  flap  to  cover 


ticulation  of  scap 

idltion' TiSiii'''cune'i;   '*  Ton  the  plantar  surfiice  of  the  articulation  are 
form  and  first  metatarsal;   two  or  tlircc  sesamoid  boncs ;  the  intcrarticular 
line  is  farther  from  the  interdioital  fold  tlian  in 


D,  articulation  of  astragalus 
and  sraj.liiiid  :  A',  ns  caleis; 

m\d'cubo\d\''///artiouh^^^^^^^^^    tlic  hand,  but  tiie  second  space  is  much  nearer 

of  cuboid    and    tiftli   meta 
tarsal. 


the  joint  than  the  others. 

The  oval  method  is  as  follows :  Holding  the 
toe  with  the  finger  and  thumb,  commence  an  incision  over  the  joint,  .,1, 
B  (Fig.  371),  and  carry  it  downward  and  forward  along  the  side  of  the 
toe  to  the  commissure  of  the  toes,  around  under  the  toe,  along  the  trans- 
verse linear  depression  to  the  opposite  side,  and  thence  up  to  the  point 


AMPUTATION. ' 


835 


of  commencement ;  divide  the  extensor  tendons  and  lateral  ligaments 
with  the  point  of  the  knife,  open  the  joint,  and  complete  the  disarticula- 
tion bv  cutting  the  tissues  upon  the  under  part  of  the  joint. 

Tiie  xingk  phuitar  fiap  requires  a  transverse  incision  over  the  joint, 
and  hiteral  incisions  to  divide  its  connectii)ns ;  depress  the  toe  and  pass 
the  knife  through  the  joint  and  along  the  under  surface  of  tlie  bone  until 
a  sufficient  flap  is  formed;  or,  dissect  off  the  flap  from  before  backward. 
The  lateral  flap  for  the  great  and  for  the  little  toe  is  made  on  the  same 
])lan  as  the  oval  (Fig.  371). 

Disarticulation  of  all  of  the  toes  through  the  metatarso-phalangeal 
artit'ulations  requires  the  "operator   to   note   that  these  joints,   a,  b,   c 


Fk;.  371. 


Fio.  372. 


.4,  disarticulation  of  the  second  pluilanx 
of  a  toe  by  the  raclcet  or  oval  incision : 
H,  disarticulation  of  the  great  toe  by 
the  racket  or  oval  incision. 


DisarticuUuiuu  of  the  great 
toe  by  internal  plantar 
flap. 


Fig.  373. 


(Fig.  373),  represent  a  curved  line  with  its  convexity  downward,  due 
to  tlie  ditt'erence  in  the  metatarsal  bones  ;  the  second  is  half  a  line 
longer  than  the  first,  the  third  is  half  a  line  shorter 
than  the  second,  the  fourth  is  half  a  line  beliind  the 
third,  the  fifth  is  still  farther  bcliind.  The  single 
flap  is  made  in  nearly  the  same  manner  as  in  am- 
putation of  all  the  fingers.  If  the  operation  is  on 
the  left  foot,  grasp  the  toes  with  the  left  liand,  the 
thumb  applied  to  the  backs  of  the  toes,  and  make  a 
.semicircular  incision  in  front  of  the  joints,  commencing 
at  the  internal  side  of  the  head  of  the  first  metatarsal 
bone,  and  ending  at  the  external  side  of  the  fifth  ;  dis- 
sect up  the  flap,  open  the  joints,  and  divide  the  lateral 
ligaments  with  tiie  point  of  the  knife  ;  now  pass  the 
knife  behind  the  phalanges  and  cut  a  flap  from  the 
plantar  .surface.  Or,  niake  the  plantar  flap  by  extend- 
ing an  incision  along  the  cutaneous  fold  at  the  base  of  the  phalanges  and 
dissecting  backward  (Fig.  374). 

Amputation  through  the  metatarsal  bones  is  performed  with  plantar 
and  dor.sal  flaps,  as  on  the  metacarpus.  Make  a  curved  incision  on  the 
dorsum  of  the  foot,  convex  downward,  dividing  tiie  soft  parts  down  to 
the  bone  ;  transfix  the  j)lantar  surface,  grazing  the  bones,  and  make  a 


Amputation  of  the 
toes. 


836 


OPERATIVE  SURGERY. 


flap  reaching  to  the  commissure  of  the  toes;  divide  tlic  interosseous 
muscles  with  the  point  of  the  knife,  apply  a  six-tailed  retractor,  and 
divide;  the  bones  with  a  fine  saw  (Fig.  370). 

J)is(irli('nJ(iti(>ii  of  (lie  first  mefdtursdl  bone  is  best  jxTfuriued  bv  the 
oval  method.  The  articulation  is  one  or  two  lines  behind  the  tirst  pro- 
jection found  on  the  posterior  portion  of  the  metatarsal  bone,  and  an 
inch  anterior  to  the  prominence  of  the  scaphoid,  E  (Fig.  370)  ;  the  direc- 
tion of  the  line  of  articulation  is  from  within  forward  and  outward. 


Fui.  374. 


Fig.  375. 


Aiuinitation   througli    the  metacarpal  bones. 


Fig.  376. 


Commence  two  lines  behind  the  joint,  a  (Fig.  376),  an  incision  di- 
rected obliquely  from  within  outward  to  the  commissure  of  the  toes,  e, 

and  pass  around  the  base  of  the  first 
phalanx,  following  the  crease  on  its 
plantar  surface  ;  withdraw  the  liistoury 
and  replace  it  on  the  internal  side  of  the 
phalanx,  b,  in  the  inferior  angle  of  the 
incision,  ascend  on  the  internal  side  of 
the  metatarsal  bone  and  phalanx,  and, 
following  a  line  slightly  oblique  from 
within  outward,  rejoin  the  point  of  com- 
mencement ;  the  skin  being  cut,  ilivide 
successively  in  the  \\'holc  extent  of  the 
incision  the  extensor  tendons  of  the  toe  and  fibres  of  the  dorsal  inter- 
osseous muscle.  Dissect  out  the  bone  (Fig.  377),  leaving  the  sesamoid 
bones  in  the  phalangeal  articulation  ;  divide  the  internal  ligament,  hold- 
ing the  point  of  the  instrument  |)erpendicularly  and  the  edge  sliglitly 
obli(|ue  from  within  outward  and  from  behind  forward  to  follow  the 
direction  of  the  joint ;  next  divide  the  snjierior  ligament,  and  direct  the 
bistoury  upward  and  push  its  point  at  an  angle  of  forty-five  degrees  into 
the  interosseous  space  formed  by  the  external  surface  of  the  first  cunei- 
form and  the  extremity  of  the  second  metatarsal  bone ;  when  the  point 


Incision   for  removal  of  great  toe  and 
metatarsal  bone. 


AMPUTATION. 


837 


has  pcnotratod  to  the  plantar  layer  raise  the  blade  again  to  the  perpendic- 
ular and  divide  the  interosseous  ligament. 

Disarticu/dtion  of  the  fifth   metatarsal  bone  is  by  tiie  oval  method. 
This  bone  artieulates  with  the  cuboid,  /'  (Fig.  370),  by  a  triangular  sur- 


FlG 


Amputation  of  the  great  toe  by  the  oval  method. 


face,  and  with  the  fourth  metaearjtal ;  it  has  a  tubercle  on  the  external 
part  of  its  base,  which  is  easily  felt  and  into  which  is  inserted  the  pero- 
neiis  brevis  muscle;  the  line  of  the  articulation  is  ol)li(juely  forward  and 
inward.  Commence  an  incision  just  behind  the  joint,  carry  it  forward 
toward  the  commissui-e,  thence  under  the  toe,  along  the  transverse  linear 
depression  to  the  opposite  side,  and  then  along  the  external  margin  to 
the  point  of  departure  ;  dissect  (Fig.  378)  the  soft  parts  from  the  bone 
and  enter  the  joint  found  just  behind  the  tubercle;  from  the  outside 
divide  the  ligaments  which  unite  it  to  the  fourth  metatarsal,  and  com- 
plete the  operation  by  dividing  the  plantar  ligaments. 

Fig.  378. 


Amputation  of  the  little  toe  nnil  its  metatarsal   bone  by  the  raeket-shaped  incision. 

DharHciiIatio)!  of  sinf/Ie  iiirtafiirxal  hnnex  mav  be  made  bv  the  oval 
method,  as  described  fur  similar  ojierations  on  the  hands. 

Disurtictildtinn  of  the  two  outer  nietaiarsal  bones  is  made  as  follows: 


838 


OPERATIVE  SURGERY. 


Imh.  379. 


Commence  an  incision  ;i  finger's  breadtii  bciiind  the  juint  of  the  fifth 
metatarsal  bone,  in  the  niiddle,  between  tlie  articnla- 
tion  of  the  two  bones ;  carry  it  forwaril  to  the  com- 
niissnre,  tlien  along  the  under  surface  in  tlie  trans- 
verse line  to  the  outer  side  of  tlie  little  toe,  and 
tiiencc  back  to  the  beginning  ;  dissect  tlie  soft  parts 
from  the  bones,  divide  the  lateral  ligament,  and  dis- 
articulate the  joints  by  entering  them  from  tiie  out- 
side and  following  the  line  above  given  (Fig.  379). 

Disdiiicnldlioii  at  the  turso-mctdtdrnd/  drtirii/dtioii 
(Hey's  operation)  is  effected  as  follows :  (irasp  tlie 
sole  of  the  foot  (the  right)  with  the  left  hand,  placing 
the  thumb  on  the  outer  side  of  the  proximal  end  of 
of  the  fifth  metatarsal  bone,  a  (Fig.  380),  and  the 
index  finger  at  tlie  extremity  of  the  first  metatarsal 
bone,  or  one  incli  anterior  to  the  prominence  (»f  the 
scaplioid,  Ij  ;  make  a  semilunar  incision,  witli  its  con- 
vexity looking  downward,  from  without  inward,  across  the  dorsum  of 
the  foot,  passing  about  iialf  an  inch  below  the  articulation  down  to  the 
bones  ;  divide  the  dorsal  ligaments  with  the  point  of  the  knife,  carrying 
it  along  the  line  of  the  articulation  from  without  inward,  recollecting 
that  the  articulation  of  the  second  metatarsal  lies  four  lines  behind  the 
first  and  third  :  this  mortise,  containing  the  liead  of  the  second  metatar- 
sal, is  opened  by  entering  the  knife  between  the  internal  cuneiform  and 
the  head  of  the  first,  its  edge  being  turned  upward  and  making  an  angle 
of  forty-five  degrees  with  the  axis  of  the  foot  (Fig.  381) ;  now  carry  the 


Incision  for  removal  of 
two  toes. 


Fig.  380. 


Fig.  381. 


...b 


Disarticulating  second  metacarpal  joint. 

knife  up  to  a  right  angle,  its  point  traversing 
the  whole  of  the  inner  surface  of  the  mortise,  in 
order  to  ensure  the  division  of  the  interosseous 
ligament ;  then  divide  that  on  the  outer  surface, 
depress  the  metatarsus  to  separate  the  articular 
surfaces,  and  divide  the  remaining  ligamentous 
attacliments,  especially  on  the  plantar  aspect  of 
tiie  articulation,  so  that  the  knife  may  be  readily  carried  beneatli  the 
heads  of  tlic  metatarsal  bones ;  cut  out  from  the  sole  of  the  foot  a  flap 


Points  of  incision  for  removal 
of  foot  at  tarso-metatarsal 
articulation. 


AMPUTATION. 


839 


somewhat  larsz:pr  at  its  internal  tluin  at  its  external  part  (Fig.  382), 
and  extending  internally  nearly  to  tiie  base  of  the  great  toe ;  externally 
it  may  be  of  less  extent.     Do  not  include  the  sesamoid  bones  in  the  flap. 


Fig.  382. 


Fig.  383. 


Plantar  llap. 


Fig.  384. 


Formatiou  of  plantar  flap. 

Or,  a  plantar  flap  may  be  made  by  carrying  a 
curved  incision  from  the  internal  extremity  of 
the  dorsal  incision  (Fig.  383)  to  the  sesamoid 
bones,  then  curviny;  forward  across  the  sole  of 
the  foot  to  the  junction  of  the  anterior  with 
the  middle  third  of  the  fifth  metatarsal  bone, 
thence  to  the  beginning  of  the  dorsal  incision. 

Fig.  385. 


Chopart's  amputation. 


Stump  after  amputation. 

The  stump  after  this  operation  is  useful  (Fig.  384). 

Mcdio-tarsal  disarticulation  (Chopart's)  is  still 
ap])rovcd  and  perfirmed  by  surgeons,  but  is  much 
inferior  in  utility  to  Syme's  amputation  (Figs.  386, 
387,  Treves). 

The  line  of  articulation,  D  (Fig.  370),  is  determined  as  follows :  On 
the  internal  surface  o?  the  foot,  about  one  inch  below  the  end  of  the 
malleolus,  two  ])rominences  are  readily  recognized  on  the  same  plane : 
the  joint  is  midway  between  them  ;  on  the  external  side  it  is  six  lines 
behind  the  ju-oininence  of  tiie  tifth  metatarsal  bone.  The  centre  of  the 
articulation  is  immediately  in  front  of  the  iicad  of  the  astragalus,  which 
is  made  prominent  by  extending  and  abducting  the  foot.  The  line  of 
the  articulation  is  changed  according  as  the  foot  is  flexed  or  extended ; 


840 


OPERATIVE  SURGERY. 


when  it  is  flexed  tlie  articular  surfaces  of  the  astragalus  and  calcaneum 
are  nearly  on  the  same  line  ;  when  extended  the  calcaneum  is  at  least 
three  lines  in  front.     Holding  the  foot  (left)  in  the  hand,  the  pahn  on 


Fig.  .'iSi;. 


Outer  siile  of  foot :  A,  Chopart's  amputation  ;  B,  Syrae's  amputation ;  C.  subastragaloid  amputation ; 
D,  line  of  section  of  bone  in  Syme's  amputation. 

the  dorsum,  with  the  thumb  on  the  outside  and  the  index  on  the  inside, 
define  the  two  extremities  of  the  articulation  ;  make  a  semilunar  incision 
between  these  two  points,  the  middle  of  which  is  half  an  inch  lievond 
the  articulation  ;  then,  passing  the  heel  of  the  knife  under  tlie  left  thumb, 
its  handle  inclined  as  above,  open  the  joint  in  tlie  direction  jHiintcd  out; 
when  the  joint  is  half  opened,  cany  the  knife  in  front  of  the  head  of 

Fig.  387. 


Inner  side  of  foot:  A,  Chopart's  amputation ;  B,  Syme's  amputation  ;  C,  subastragaloid 

amputation. 

the  astragalus,  and  cut  the  dorsal  ligaments  without  penetrating  between 
the  bones  ;  carrying  the  knife  to  the  other  side  of  the  foot,  the  heel  in- 
clined toward  the  toes  at  an  angle  of  forty-five  degrees,  finish  ojiening 
the  external  side  of  the  joint;  the  dorsal  ligaments  being  thus  divided, 
push  the  point  of  the  knife  under  the  external  and  anterior  side  of  the 
astragalus,  with  its  edge  directed  forward,  and  cut  the  interosseous  liga- 
ment in  the  direction  of  the  articular  surface  of  the  calcaneum ;  the  joint 


AMPUTATIOy. 


841 


being  now  open,  carry  the  knife  under  the  jilantar  h'sjaments  and  pass  it 
under  the  bunes,  grazing  them,  tu  cut  a  sutficient  flap  (Fig.  o8S),  avoid- 


FiG.  388. 


Fig.  3S9. 


Chopart's  amputation. 


Stump  after  Chopart's 
amputation. 


Fig.  390. 


ing  the  protuberances  of  the  cuboid  and  scaphoid,  and,  farther  on,  of 
tlie  fir.st  and  fifth  metacarpal  bones ;  the  foot  during  this  time  i.s  hehl  in 
the  horizontal  position  ;  raise  the  handle  of  the  knife  sligiitlv,  to  follow 
more  exactly  the  concavity  of  tlie  tarsus  and  metatarsus. 

Disiirfiriilcdioii  of  the  fursu>s  under  the  astragalus  (subastragaloid) 
may  be  ])ractised  as  follows  :  Commence  at  the  outer  edge  of  tlie  inser- 
tion of  the  teiido  Achillis,  A  (Fig.  391),  and  make  an  incision  through 
the  skin  forward  two  fingers'  breadth  below  the 
malleolus,  to  witliin  a  finger's  breadtli  of  tlie  upper 
part  of  the  base  of  the  fiftii  metatarsal  bone  ;  now 
carry  the  incision  upward,  forward,  and  inward,  so 
as  to  reach  the  inner  margin  of  the  tendon  of  the 
extensor  proprius  pollicis  just  at  the  first  metatarsal 
articulation,  C  (Fig.  387) ;  then  cut  downward  and 
forward,  and  enter  the  sole  a  finger's  breadtli  in 
front  of  tlie  dorsal  wound  ;  next  carry  the  incision 
\\ith  a  gentle  forward  curve,  outward  and  back- 
ward, until  it  can  be  made  continuous  with  the  first 
portion  of  the  wound  below  the  outer  malleolus,  I) 
(F'ig.  386).  Retract  the  integument  half  an  inch, 
and  divide  the  dor.sal  and  plantar  structures  and 
teiido  Achillis  ;  separate  them  from  the  lioues,  great 
care  being  taken  to  preserve  uninjured  the  vessels 
contained  in  the  inner  part  of  the  plantar  fiap ;  now 
di.sarticulate  the  cuboid  and  scaphoid  from  the  as- 
tragalus, passing  the  knife  between  tlie  astragalus  and  os  calcis,  .so  as  to 
divide  the  interosseous  ligament ;  separate  the  .soft  parts  from  the  under 
surface  of  the  os  calcis  wiiilo  .<o  twisting  the  foot  as  to  make  the  tissues 
tense  ;  di.sarticulate  the  os  ctdcis  from  tiie  a.sti'agalus. 

In  Tripier'.^  operation  the  os  calcis  is  sawu  through  in  a  direction 


Triplet's  operation  of  the 
foot. 


842 


OPERATIVE  SURGERY. 


from  behind  ami  within  forward  and  outward,  so  as  to  leave  a  surface 
wliic'h  will  be  at  right  angles  with  the  axis  of  the  tibia  when  the  limb 
assumes  the  position  for  walking,  A,  B  (Fig.  390). 

Farabeuf   makes  a   large   internal  and    plantar   flaj),  .1    (Fig.  392, 
Treves).  '  


Begin 


it  the  outer  margin  of  the  tendo  Aohillis,  eurve  tiie 


Fig. 391. 


Fio.  392. 


Inner  and  outer  sides  of  the  right  foot,  to  show  the  incisions  in 
Farabeuf 's  subastragaloid  amputation :  V,  the  lines  of  Ver- 
neuirs  subastragaloid  amputation.  (For  otlier  references  see 
text.) 


Plantar  incisions  :  .1,  Lisfranc; 
B,  Chopart;  C,  Pirogoff;  D, 
Syme  ;  E,  Faral)euf 's  subas- 
tragaloid amputation :  F, 
Farabeuf's  amputation  at 
the  ankle. 


incision  up  to  a  point  an  inch  below  the  external  malleolus,  then  forward 
to  B  on  the  line  of  the  fifth  metatarsal  bone,  with  the  joints  between 
tlie  scaphoid  and  cuneiform  bones ;  then  across  the  dorsum  to  A'  (Fig. 
391),  to  the  tendon  of  the  exten.sor  proprius  pollicis ;  the  incision  crosses 
the  inner  border  of  the  foot  along  the  line  of  the  cuneo-metatarsal  joint ; 
then  across  the  centre  of  the  sole  to  I),  whence  it  curves  back  along  the 
outer  border  of  the  foot  to  tiie  external  border  of  the  os  calcis,  E,  then 
upward  to  the  point  of  commencement,  ^1. 

Verneuil  commences  the  incision  at  about  the  same  point,  and  carries 
it  forward  to  within  an  inch  of  the  posterior  and  internal  extremity  of 
the  fifth  metatarsal  bone,  thence  with  a  downward  curve  across  tlie 
dorsmn  of  tlie  foot  to  the  middle  of  the  internal  cuneiform  bone,  thence 
across  the  sole  of  the  foot  from  M'ithin  outward  and  from  before  back- 
ward to  the  commencement  (Fig.  391,  Treves). 


AMPUTATION    AT   THE    ANKLE-JOINT. 

Disarticulation  of  the  ankle-joint  with  a  heel-flap  has  justly  been 
regarded  as  one  of  the  greatest  improvements  in  amputation  of  modern 
times.     Not  only  is  the  mortality  of  this  operation  very  small,  but  when 


AMPUTATION. 


843 


compared  with  tlic  stumps  made  at  any  other  point  of  the  foot  or  leg, 
those  made  at  the  ankle-joint  have  proven  eminently  superior,  being 
less  subject  to  such  untoward  complications  and  sequelas  as  ulcers,  con- 
gestions, necrosis,  and  chronic  tenderness,  which  impair  the  subsequent 
usefulness  of  appropriate  and  well-adapted  compensative  apparatus. 
The  broad  articular  surface  of  the  lower  extremity  of  the  tibia,  with 
its  internal  projection,  the  internal  malleolus,  and  the  large  projecting 
extremity  of  the  fibula,  the  external  malleolus,  form  a  mortise  to  which 
the  lateral  and  upper  surfaces  of  the  astragalus  are  so  accurately  adapted 
that  there  can  he  no  lateral  motion,  and  disarticulation  can  only  be 
accomplished  when  the  foot  is  firmly  extended  and  the  knife  penetrates 
the  anterior  part  of  the  articulation. 

Syme's  ainpufution  is  as  follows  :  Place  the  foot  at  a  right  angle  to 
the  leg;  enter  the  knife  at  the  point  of  the  external  malleolus,  B  (Fig. 
386),  and  carry  it  directly  across  the  sole  of  the  foot  to  a  point  opposite, 
or  six  lines  below  the  internal  malleolus,  B  (Fig.  387) ;  the  posterior 
tibial  artery  divides  beneath  the  internal  annular  ligament  into  the  in- 
ternal and  external  plantar  ai-feries,  and  if  the  incision  extends  to  the 
point  of  the  internal  malleolus,  the  vessel  may  be  divided ;  join  the  two 
extremities  of  this  incision  by  an  anterior  incision  in  a  direct  line  over 
the  instep,  so  that  the  cicatrix  may  come  well  in  front  (Fig.  393).  In 
dissecting  the  posterior  flap,  place  the  fingers  of  the  left  hand  upon  the 
heel,  and  with  the  thumli  press  the 
edge  of  tiie  flap  tirndy  Ijackward,  cut- 
ting between  the  nail  of  the  thumb 
and  the  tuberosity  of  the   os   calcis 

Fig.  393. 


Fig.  394 


Symo's  amputation  of  the  foot :  anterior 
incision  and  disarticulation. 


Syme's  amputation  of  the  foot  : 
cleaning  the  os  ealcis. 


(Fig.  304),  so  as  to  avoid  lacerating  the  soft  parts ;  the  tendo  Achillis  is 
exposed  and  divided.     Disarticulate  the  foot  and  saw  off  the  malleoli,  D 


844 


OPHRAriVE  SURGERY. 


(Fij;.  380) ;  leave  the  articular  extremity  of  tiie  tibia  uninjured,  fur  it  is 
better  not  to  interfere  witii  tlie  bone  if  it  is  iiealtliy. 

There  are  many  metiiods  of  niocHfying  the  construction  of  flaps  to 
cover  tlie  ends  of  the  tibia  and  fibula,  adapted  to  the  various  forms  of 
injury  of  the  soft  ])arts  :  all  eoverinirs,  whether  from  tlie  sole,  the  lateral 
surfaces,  or  IVom  tlie  dorsum  of  the  loot,  are  useful,  and  should  be  pre- 
served for  that  purpose  when  tiie  heel-flap  is  wantinij.  In  the  first 
examjile  insert  the  knife  in  the  middle  line  of  the  posterior  aspect  of  the 
ankle,  on  a  level  with  the  articulation  ;  carry  it  doM'nward  obliquely 
across  the  tendo  Achillis  toward  the  external  border  of  the  jilantar  aspect 
of  the  heel,  alonii'  which  it  is  continued  in  a  semilunar  direction  ;  curve 
the  incision  across  the  sole  of  the  foot,  and  terminate  it  on  the  inner  side  of 
the  tendon  of  the  tibialis  antieus  alioiit  an  inch  in  front  of  the  inner  malle- 
olus; carry  the  second  incision  across  the  outer  aspect  of  the  ankle  in  a 
semilunar  direction,  between  the  extremities  of  the  first  incisions,  the  con- 
vexity of  the  incision  downward,  and  passing  half  an  inch  below  the 
external  malleolus.  In  lloux's  ojieration  make  an  incision  from  the 
junction  of  the  tendo  Achillis  with  the  os  calcis  around  the  external  sur- 
face of  the  foot  immediately  below  the  external  malleolus ;  then  carry  it 
inward  toward  the  internal  border ;  curve  forward  and  al)out  an  inch  in 
front  of  the  ankle-joint ;  then  pass  along  the  internal  border  of  the  foot 
to  the  ])oint  of  dt'parture. 

In  otiti'oplasfic  ampuUdlon  of  the  anl;h -joint  (PirogofT)  the  covering  of 
the  stump  consists  of  the  posterior  jxirt  of  the  os  calcis  enclosed  in  the 
integument  of  the  heel.  The  results  are  favorable,  but  the  additional 
length  of  limb  is  not  desirable  for  an  artificial  limb.  Commence  the 
incision  close  in  front  of  the  outer  malleolus  ;  carry  it  downward  and  for- 
ward nearly  to  the  posterior  extremity  of  the  fifth  metacarpal  bone,  into 
the  sole  of  the  foot,  ^1  (Fig.  395),  then  transversely  across  the  sole,  and 


Fig.  39o. 


Plrogoff's  amputation:  A,  cutaneous  incision,  outer  side  ;  B.  line  of  section  of  the  bones. 

lastly  obliquely  upward  and  backward  to  the  inner  malleolus;  terminate 
it  a  coujile  of  lines  anterior  to  the  malleolus  ;  divide  all  the  soft  parts  at 
once  quite  down  to  the  os  calcis ;  now  connect  the  outer  and  inner  ex- 
tremities of  this  first  incision  by  a  second  semilunar  incision,  the  convex- 


AMPUTATION. 


845 


Fig.  396. 


itv  of  which  looks  forward,  carried  a  few  lines  anterior  to  the  tibio-tarsal 
articulation  ;  cut  through  all  the  soft  parts  at  once  down  to  the  hones, 
and  then  proceed  to  ojien  the  joint  from  the  front,  cutting  through  the 
lateral  ligaments,  and  thus  exarticulate  the  head  of  the  astragalus  ;  now 
place  a  small,  narrow  amputation  .saw  obliquely  upon  the  os  calcis  behind 
the  astragalus,  and  saw  through  the  bone  carefully,  or  the  anterii)r  sur- 
face of  the  tendo  Achillis,  which  is  only  covered  by  a  layer  of  fat  and  a 
thin  fibrous  sheath,  may  be  injured  ;  raise  the  short  anterior  flap  from  the 
two  malleoli,  and  make  a  section  of  the  tibia  and  fibula  just  above  the 
articular  surfaces ;  turn  this  flap  forward,  and  bring  the  cut  surface  of 
the  OS  calcis  in  apposition  with  the  cut  surface  of  the  tibia  (Fig.  396) ; 
the  tendons  nuist  not  be  cut  off  too  near  the 
point  where  their  .synovial  sheaths  are  cut 
through  ;  if  (Uit  too  short,  the}'  conceal  them- 
selves in  the  fibrous  canal,  or,  when  the  limb  is 
moved,  slip  upward  out  of  their  sheaths.  Other 
methods  are  outlined  in  the  illustration. 

Sujini-jiirt/lcolar  (iiiijiiiiiiHon  should  always 
be  preferred  to  any  operation  at  a  higher  ])(>int, 
and  the  flap  should  lie  taken  from  the  firmest 
tissues  accessible.  The  following  method 
(Guyon),  B  (Fig.  401),  gives  a  good  stump: 
Make  an  incision  from  the  base  of  the  exter- 
nal malleolus,  posteriorly,  around  the  external 
surface  of  the  foot  iunnediately  below  the 
malleolus,  and  inward  toward  the  internal 
border,  but  curved  forward  to  a  point  an  inch 
in  front  of  the  ankle-joint  (Fig.  397) ;  make 
a  similar  incision  on 
Fig.  397.  the  internal  surface,  and 

unite  the  two  behind 
by  a  transverse  incision 
having  a  slight  con- 
vexity downward  ;  separate  the  soft  parts  from  the 
bones,  and  saw  the  tibia  and  fibula  at  the  lia.se  of 
the  malleoli  about  an  inch  above  the  articular  sur- 
face. 


Pirof^off 's  amputation  :  appearance 
(if  the  parts  after  removal  of  mal- 
leoli (J.  E.  Eriehsen). 


AMPUTATION    OF    THE    LEG. 

Amputation  of  the  leg  involves  new  and  most 
Supramalleolar  amputation.  im])ortant  jirinciplcs,  both  ill  operative  and  mechan- 
ical surgery.  At  no  other  point  is  it  more  neces- 
sary to  seciu'e  a  sound  and  u.seful  stump  than  in  this  part.  This  is  due 
to  the  incessant  use.  to  which  it  must  be  applied  and  its  ex]iosure  to 
injury.  But  it  presents  intrinsic  difliculties  in  the  application  of  the 
ordinary  methods  of  amputation.  This  is  apparent  in  the  development 
of  the  muscles  of  the  calf,  the  tajiering  form  of  the  lower  portion,  and 
the  subcutaneous  position  of  the  tibia.  The  circular  flap  cannot  be  re- 
tracted without  dividing  it  longitutliiially  ;  the  single  jiosterior  fla])  is  of 
immense  size,  and  is  counteracted  only  by  the  integument  of  the  anterior 
part  of  the  leg;  the  double  flap  gives  a  great  inequality  of  flaps;  the 


84G 


OrT:n.  1 TIVE  SVRGF.R Y. 


single  external  flaj)  leaves  liie  crest  of  the  tibia  hut  slightly  covered. 
The  results  of  amputation  of  the  leg  have,  in  consequence  of  these  con- 
ditions, been  more  unsatisfactory  than  at  any  other  point.  Necrosis  of 
the  tibia,  conical  stumps,  ulcerated  coverings,  and  tender  cicatrices  have 
been  the  rule  when  the  old  methods  have  been  jtreferred.  J^)Ut  bilateral 
Haps  of  the  soft  parts  and  periosteal  coverings  of  tiie  tibia  give  a  tirm, 
compact,  and  enduring  stump. 

Tlie  place  of  division  of  the  bone  may  be  at  any  point,  but  at  the 
lower  part  of  the  leg  the  commencement  of  the  calf  is  most  favorable  for 
a  symmetrical  stump,  and  at  the  upper  part  is  to  be  preferred  a  point  two 
inclies  below  the  tubercle  of  the  jiatella,  which  permits  the  knee  to  be  bent 
and  brings  the  support  upon  tlie  condyles  of  the  femur.  An  am])utation  at 
the  latter  point  is  indicated  wlienever  tlie  leg  is  permanently  flexed  either 
at  a  right  or  at  an  acute  angle  with  the  thigh.  If  the  amputation  must 
be  very  close  to  the  joint,  disarticulation  shoidd  be  preferred,  for  the  risk 
to  the  jiatient  of  the  knee-joint  amjjutation  is  no  greater  than  of  an  am])U- 
tation  of  the  extreme  upj)er  third  of  the  leg,  while  its  practical  benefits  are 
much  superior,  as  confirmed  l)y  experience.  The  elastic  l)andage  siiould 
be  first  applied  to  a  point  above  the  knee  (Fig.  329).  The  bilateral  Haps 
here  recommended  should  be  made  as  follows:  Commence  an  incision 
with  a  large  scalpel  in  the  centre  of  the  anterior  surface  (Fig.  398),  and 

Fio.  398. 


Bilateral  flaps. 


carrj'  it  downward  along  the  side  of  the  leg  so  as  to  make  a  slightly 
curved  flap  with  its  convexity  below ;  after  the  incision  has  passed  over 
the  prominent  ]>art  of  the  leg  toward  the  posterior  surface,  incline  it 
slightly  upward  until  the  middle  of  the  limb  is  reached,  where  it  should 
be  continued  directly  up  to  the  point  at  which  the  bone  is  to  be  divided  ; 
make  a  similar  incision  on  the  oppo.site  side ;  these  lateral  flaps  should 
consist  of  the  skin  and  superficial  fascia ;  dissect  them  upward  to  the 
extent  of  one  inch  in  the  leg  and  two  inches  in  the  thigh  ;  now  make  a 
circular  division  of  the  muscles  to  the  bone  with  a  long  knife ;  saw  the 
bone  or  bones  at  tiiis  point,  and  direct  an  assi.stant  to  seize  and  hold  the 
extremity  firm  with  strong  forceps  (Fig.  333) :  with  the  perio-steal  knife 
or  the  thumb-nails  (which  are  equally  efficient)  raise  the  peri(isteum  from 
the  tibia  to  the  point  where  the  latter  is  to  be  cut ;  divide  the  bone  at  the 
base  of  the  periosteal  flap.  The  periosteum  must  be  cut  at  its  attach- 
ments to  the  linea  aspera  of  the  bone,  and  should  lie  raised  only  from  the 
tibia,  the  fibula  being  fir.st  exsected.  The  covering  thus  prepared  has  the 
integument  externally,  the  perio.steum  internally,  while  the  intervening 
tissues,  muscles,  vessels,  nerves  have  not  been  disturlied  in  the  dissection; 
the  periosteal  flap  falls  like  a  hood  over  the  end  of  the  bone,  the  skin- 


AMPUTATION. 
Fig.  399. 


847 


stump  after  bilateral  flaps. 


flaj)s  lie  in  contact  without  tension,  and  the  drainage  is  direct  from  the 
angle  of  the  wound  beneath.  "When  cicatrization  is  complete  the  cicatrix 
lies  posterior  to  tiie  end  of  the  stump,  the  cushion  is  freely  movable,  and 
the  bone  does  not  undergo  the  usual  amount  of  atrophy  (Fig.  399). 


Fi«.  400. 


Fig.  401. 


Amputation  of  leg 
rectangular  florae 
upper  third 


«.,......v».v..  w.  Its.  -^1  modifierl  circular;  B, 

rectangular  flaps  ;  ('.  antero-posterior  flaps. 


Amputation  of  leg:  A,  long  anterior  flap;  li, 
supra-nialleolar  am]>utation  by  long  poste- 
rior flap ;  C,  at  the  upper  third. 


848 


OPERATIVE  SURGERY. 


The  various  other  methods  of  opiTatinji  are  indicated  by  the  illustra- 
tions (Figs.  400,  401).  The  reetaiiguiar  Haj),  B  (Fig.  400)",  is  sometimes 
made  in  the  lower  part  of  the  leg ;  the  rules  given  as  to  the  formation 
of  the  flaps  in  this  o[)eration  must  be  stricth'  observed.  The  flap  ojiera- 
tion  is  very  often  selected  for  the  upper  part  of  the  leg,  and  is  veiy  simple 
in  its  details,  C  (Fig.  400).     Skin-flajts  and  circular  section  of  the  mus- 


Ampntation  of  the  leg  liy  the  mixed  method  (T.  Bryant). 

cles,  the  mixed  method  (Fig.  402),  is  to  be  preferred  to  the  common  flap 
amputations. 

AMPUTATION    AT    THE    KXEE-JOINT. 

This  amputation  now  ranks  among  the  most  successful  operations  both 
for  safety  and  the  usefulness  of  the  stump ;  as  compared  with  amputa- 
tions through  the  thigh  it  is  quicker,  easier,  and  requires  sim])l('r  instru- 
ments, and  there  is  less  shock  ;  the  integuments  preserved  are,  as  a  ride, 
better  adapted  to  sustain  pressure ;  there  is  less  risk  of  injury  to  flaps 
from  a  rough-sawn  bone,  and  less  retraction  of  muscles ;  the  sustaining 
power  is  more  quickly  acquired  ;  the  j^oint  of  support  is  broader  and 
better  fitted  for  pressure  ;  from  large  anastomoses  about  the  joint  the 
blo()(l-su])])ly   is  more  quickly  established. 

This  amputation  may  be  made  by  simple  disarticulation,  or  in  addition 
the  condyles  of  the  femur  may  be  sawn  through.  If  there  is  no  disease 
and  ample  flaps  can  be  made,  the  bone  should  not  be  sawn.  The  follow- 
ing opinion  of  an  experienced  mechanical  surgeon  (Dr.  E.  D.  Hudson) 
is  most  instructive  : 

"  The  practice  of  dividing  the  condyles  cannot  be  sustained  by  any 
rational  hypothesis  nor  practised  on  any  scientific  principles  :  except  dis- 
ease or  injury  of  the  condyles  compels  their  excision,  their  osseous  cover- 
ing and  cartilage  investments  should  be  kept  inviolate  from  knife  and 
saw,  for,  as  constituted,  they  are  the  strongest,  most  tolerant,  and  import- 
ant supports  in  the  entire  body  ;  the  inter-condyloid  fossa  is  readily 
filled,  even  with  the  convexity  of  the  condyles,  with  a  neatly-shaped 
elastic  pad  of  wool  felt  made  to  extend  over  them  for  a  cushion  in 
the  adaj)tation  of  jn-othetic  apparatus.  Equally  reprehensible  is  the 
method  of  placing  the  patella  over  the  fossa  with  a  view  to  making  that 
a  point  of  support,  and  also  of  sa^\ing  off  the  condyles  and  applying  the 
j)atella  to  the  cut  surface  :  these  and  other  ingenious  experiments  are  of 
no  practical  value." 

There  are  many  methods  of  operating,  but  the  bilateral-flaj)  method, 
devised  by  the  author,  is  to  be  preferred  for  the  reasons  above  given  ;  the 
joint  surface  of  the  bone  should  not  be  disturbed  unless  diseased,  and 


AMPUTATION. 


849 


the  patella  may  be  left  in  its  ])luce,  though  it  is  of  no  value  to  the  stump. 
The  line  of  the  articulation  lies  internally  nine  lines  above  the  promi- 
nence of  the  tibia  ;  the  lower  border  of  tlie  patella  is  on  a  line  with  the 
articulation,  and  externally  it  is  nine  lines  below  the  prominence  of  the 
external  condyle. 

Operate  as  follows  :  Select  a  large  scalpel,  and  eonuncnce  an  incision 
about  one  inch  below  the  tubercle  of  the  tibia,  and  cut  to  the  bone ; 
carry  it  downward  and  forward  beyond  the  curve  of  the  side  of  the 
leg,  thence  inward  and  backward  to  the  middle  of  the  leg,  thence 
upward  to  the  middle  of  the  popliteal  space ;  repeat  this  incision  upon 
tlie  opposite  side;  raise  the  i\:\]>,  consisting  of  all  tlie  tissues  down  to 
the  bone,  until  the  articulation  is  reached  ;  divide  the  lateral  ligaments, 
enter  the  joint,  and  sever  its  connections  internally  and  externally. 
Care  should  be  taken  that  the  incisions  incline  moderately  forward, 
down  to  the  curve  of  the  side  of  the  leg,  to  secure  ample  covering  for 
the  condyles  ;  the  incision  upon  the  internal  aspect  should  have  additional 


Fig.  403. 


Fig.  404. 


Stephen  Smith's  amijutation  at  the  knee-joint. 

fulness  for  the  ])urpose  of  ensm-ing  sufficient  flap 
for  the  internal  condyle,  which  is  longer  and 
larger  than  the  external. 

The  flaps  completely  cover  the  condyles  (Fig. 
403),  and  are  readily  approximated,  leaving  am- 
ple .<pace  for  direct  drainage  at  tlii'  upper  angle 
of  the  -woimd  ;  a  drainage-tube  may  be  inserted 
if  necessjiry  ;  tlie  flaps  arc  well  nourished  and 
union  takes  place  rajiidly,  giving  a  well-rounded 
stump  with  the  cicatrix  sunk  in  the  inner  con- 
dyloid fo.ssa  (Fig..  ;3y9). 

T)t><nrticii(<dion  u-Uh  a  hi);/  (nttcrior  flap  (Fig. 
404),  requires  an  incision  from  the  head  of  the 
fibula.  A,  or  the  margin  of  the  outer  condyle, 
B,  downward  on  the  side  of  tlie  leg  five  inches 
below  the  lower  edge  of  the  patella,  then  curved 
across  the  front  to  tlie  opjiositc  side,  thence 
upward  to  a  corresponding  jxiint  inside. 

AmpuUdhin  throiKjh  the  coikIij/c.^  (Garden), 
consists  in  reflecting  a  rounded  or  .semi-oval 
flap  of  .skin  and  fat  from  the  front  of  tlic  joint,  B,  B'  (Fig.  404),  dividing 

Vol.  1.-54 


Amputation  at  the  knee  and 
hiwer  third  i.f  tlie  thi^-h  :  A. 
flisartieuhitiuii.  luni; anterior 
ilap:  it,  aini>ntatH)n  tlirough 
the  ec)ndyle.s  (Cardeni;  C, 
modified  nap  amputation  at 
the  hiwer  tliird  of  the  tliigh 
(Syme). 


850 


OPERATIVE  SURGERY. 


everything  else  down  to  the  bone,  and  sawing  the  bone  slightly  above 
tlie  jilanc  of  the  nmsclos,  tluis  forming  a  flat-faced  stump  with  a  body 
of  integument  to  fall  over  it. 

Osteoplaatic  aiii'putation  of  the  knee  (Gritti)  consists  not  only  in  remov- 
ing a  portion  of  the  condyles,  but  also  of  incising  the  patella,  A  (Fig.  408), 
anil  placing  the  cut  surface  upon  the  sawn  condyles  for  the  purpose  of 
securing  union  of  the  bones.  Stokes  modified  this  operation  by  dividing 
tlie  bone  from  a  half  to  three-quarters  of  an  inch  above  the  condyles,  in 
order  to  secure  a  surface  better  adapted  to  the  patella. 

The  modified  circular  method  (J.  Lister)  is  as  follows :  First  cut 
transversely  across  the  front  of  the  limb  from  side  to  side,  at  the 
level  of  the  anterior  tuberosity  of  the  tibia,  and  join  the  horns  of 
this  incision  by  carrying  the  knife  at  an  angle  of  forty -five  degrees 
to  the  axis  of  the  leg  through  the  skin  and  fat ;  elevate  the  limb, 
dissect  up  the  posterior  skin-flap,  and  then  proceed  to  raise  the  ring 
of  the  integument  as  in  a  circular  operation,  taking  due  care  to  avoid 
scoring  the  subcutaneous  tissue ;  by  dividing  the  hamstrings  as  soon 
as  they  are  exposed,  and  bending  the  knee,  the  upper  border  of  the 
patella  is  exposed;  then  sink  the  knife  through  the  insertion  of  the 
quadriceps  extensor  (Fig.  405),  and  having  cleared  the  bone  inunediately 

Fig.  405. 


Lister's  ampntiitidii  through  the  condyles  hy  modified  circular  method. 


above  the  articular  cartilage,  and  holding  the  limb  horizontally,  apply 
the  saw  to  the  bone,  so  as  to  ensure  a  horizontal  surface  for  the  patient 
to  rest  on. 


AMPUTATION    OF    THIGH. 


The  thigh  is  composed  principally  of  muscular  structures,  which  sur- 
round the  femur  in  two  distinct  layers,  the  superficial  and  deep ;  the 
superficial  nuiscles  all  spring  from  the  pelvis  and  go  to  the  leg,  and  the 
lower  they  are  cut  the  more  they  retract,  and  vice  versd. 


AMPUTATION. 


851 


Observation  and  cxjierience  (E.  D.  Hudson)  teach  that  amputations 
of  tlie  thigh,  as  ordinarily  pertonned  and  ul-  Fiu.  400. 

timately  treated  with  prothetic  apparatus,  are 
unnecessarily  disabling;  but  with  the  bilat- 
eral and  periosteal  ilap,  and  as  full  length 
of  the  femur  for  leverage  as  the  injury  or 
disease  will  safely  allow,  a  quality  and  ca- 
paeitv  of  stump  may  be  obtained  which,  with 
appropriate,  well-adapted  apparatus,  will  as- 
sure the  patient  a  firm  basis  of  support  on  a 
line  with  the  axis  of  the  thigh.  Ample  lever- 
age and  adequate  motor  power  enable  him  to 
balance  his  weight  exclusively  on  his  artificial 
limb,  and  to  walk  without  a  cane  with  ease 
and  gracefulness.  The  method  of  procedure 
ret[uires  the  same  incision  as  the  operation  on 
the  leg  already  detailed  (Fig.  407).  It  is 
highly  important  to  save  all  the  blood  possible, 
and  for  this  purpose  the  elastic  bandage  should 
first  be  applied,  and  carried  to  the  hip,  where 
the  elastic  tourniquet  is  applied  (Fig.  409). 
If  the  bandage  is  not  at  hand,  the  tourniquet 
may  be  placed  loosely  around  the  thigh,  the 
thigh  raised  for  a  few  minutes  while  it  is 
rubljcd  toward  the  hip,  and  then  the  tourniquet 
is  tightened  (Fig.  40(5). 

Anfcro-jjostcrior  flaps  are  made  thus :  Stand- 
ing at  the  right  side  of  the  limb,  grasp  the  soft 
])arts  and  bring  them  forward  ;  transfix  the 
limb,  tiie  knife  grazing  the  up])er  surface  of 
the  bone,  and  make  an  anterior  flap  (Fig. 
407) ;  reintroduce  the  knife,  and,  passing  it 
under  the  bone,  make  a  posterior  flap  longer  than  the  anterior  to  com- 
pensate for  the  greater  retraction ;  complete  the  operation  as  in  the  lat- 
eral-flap method. 

Fig.  407. 


Lister's  method  for  bloodless 
amputation. 


Amputation  of  the  thigh  by  flap  operation. 


852 


OPEBAriVE  SURGERY. 


Another  method  is  as  follows:  Stamliiiii  ;it  the  ritilit  side  of  the  linih, 
frrnsp  the  thij>'li  with  the  left  hand,  ])lacin<r  the  tini^iTs  aiul  tlniml)  on 
opposite  points;  aj)ply  the  heel  of  a  loni;-  amputating  knife  on  the  iarther 
side  of  the  linih  at  the  ends  of  the  tingers,  and  draw  it  in  a  seniieirenlar 
direction  over  the  limb  to  the  end  of  the  thumb,  dividing  by  this  single 
sweep  all  the  soft  parts  down  to  the  bone ;  without  removing  the  knife 
withdraw  it  sufficiently  to  enter  the  point  at  the  angle  of  the  wound  and 
transfix  tlie  limb,  passing  under  tiie  bone  to  the  angle  of  the  wound  on 
the  opjwsite  side ;  cut  a  fiap  of  the  requisite  length  from  tlie  posterior 
part  of  the  thigh. 

Other  methods  of  operating  are  indicated  in  Fig.  408. 


DISARTICUI^ATION    AT    THE    HIP-JOINT. 

The  hip-joint  is  formed  by  the  liead  of  the  femur  and  t]i(>  acetabu- 
lum, into  which  it  is  received  ;  its  ligaments  are  the  round  ligament, 
which  attaches  the  head  of  the  bone  to  the  bottom  of  the  cavity,  and  the 

capsular  ligament,  surrounding  the  joint ; 
Fig.  408.  it  is  deejdy  situated   under  thick  and 

powerful  muscles,  and  can  be  felt  only  on 
the  anterior  part ;  it  nuist  be  recollected 
thatthe})laneof  the  margin  (if  the  acetal)- 
ulum  inclines  downward  and  forward, 
projecting  more  posteriorly  than  ante- 
riorly ;  the  arteries  are  the  femoral,  the 
obturator,  the  ischiatic,  and  external  and 
internal  circimifiex.  The  following  are 
anatomical  guides  to  the  joint:  (1)  The 
anterior  inferior  spinous  process  of  the 
ilium  is  three-quarters  of  an  inch  above 
the  superior  margin  of  the  acetabulum ; 

Fig.  409. 


^.Gritti's  amputation  at  the  knee :  A',  lines 
of  division  of  bone ;  B,  long  anterior  flap 
(S^dillot);  fi',  division  of  liiine;  C,  ampu- 
tation at  lower  tliinl  (.T.  sprneei:  r'.  di- 
vision of  bone ;  D,  disarticulation  of  hip. 


Arrest  of  hemorrhage :  operations  on 
tlie  hip-joint.  The  dotted  line  is  the 
incision  for  the  oval  amputation  at 
the  hip-joint. 


AMPUTATION. 


853 


Fig.  410. 


the  anterior  superior  spinous  process  is  about  iin  inch  and  three-quarters 
above  the  same  point  and  tin-ec-cpiarters  of  an  incli  to  its  outer  side.  (2) 
The  anterior  border  of  the  acetabuhini  is  from  an  ineii  to  an  inch  and  a 
quarter  to  the  outside  of  the  spine  of  the  pubes.  (3)  The  axis  of  the 
horizontal  ramus  of  the  pubes,  extended  by  an  imaginary  line,  crosses 
the  acetabulum  at  the  junction  of  its  superior  with  its  middle  third.  (4) 
Tlie  superior  border  of  the  trochanter  major  is  on  a  level  with  the  upper 
third  of  tlie  cavity  of  the  joint. 

Amputation  may  be  performed  by  the  single  flap,  anterior  or  internal ; 
the  double  flap,  lateral  or  antero-posterior ;  the  oval ;  and  the  circular 
(Fig.  408).  These  different  methods  have  been  almost  indefinitely  modi- 
fied. Hemorrhage  should  Ijc  prevented  by  the  application  of  the  elastic 
bandage  (Fig.  409) ;  or  by  the  figure-of-8  elastic  bandage,  carried  above  the 
iliac  crests  around  the  liip,  and  the  transfixion  l)y  a  single  needle  passed 
in  front  of  the  neck  of  tlie  femur  and  beneath  the  vessels,  over  the  ends 
of  Avhich  a  rubber  cord  is  carried  only  in  front  of  the  thigh  (Trendelen- 
burg), or  by  the  elastic  bandage  applied  above  two  needles  (Wyeth) 
(Fig.  412) ;  "this  latter  has  jiroved  the  most  effective  method  yet  devised. 

The  irrfieal  and  ciiTitfar  method  (F.  Jordan)  is  performed  as  follows 
(Fig.  410)  :  Alake  an  incision  along  the  outer  side  of  the  thigh,  extend- 
ing downward  from  tiie  top  of  tlie  trochanter  for  six  or 
more  inches ;  enucleate  the  head  of  the  femur  from  the 
acetabulum  ;  sejwrate  the  muscles  and  tissues  ;  now  make 
a  circular  incision  down  to  the  bone  at  the  requisite  point ; 
saw  the  bone  ;  while  an  assistant  seizes  and  holds  firmly 
the  lower  end  of  the  u])|ier  fragment,  complete  the  disar- 
ticulation. If  the  artery  is  not  compressed  sufficiently 
certainly  to  prevent  hemorrhage,  it  may  be  tied  in  the 
flap. 

Double  aidero-posterior  flaps  are  made  thus:  The 
elastic  bandage  being  in  plai'c,  standing  on  the  outside  of 
the  limb,  insert  tlie  point  of  a  long  catling  about  midway 
between  the  anterior  superior  spinous  process  of  the  ilium 
and  trochanter  majc^r,  keeping  it  rather  nearer  the  former 
than  the  latter  ;  then  run  it  across  the  fore  part  of  the 
neck  of  the  bone,  and  push  it  through  the  skin  on  the 
opposite  side  about  two  or  three  in(thes  from  the  anus ; 
next  carry  it  downward  and  forward,  so  as  to  cut  a  flap 
from  tiie  anterior  aspect  of  the  tliigh  about  four  to  six 
inches  in  length.  When  the  blade  is  entered  the  limb  should  be  held 
up,  and  even  slightly  l)ent  at  the  joint :  the  instrument  will  then  pass 
along  more  readily  than  if  all  the  textures  were  thrown  on  the  stretch ; 
moreover,  there  is  greater  certainty  of  passing  it  behind  the  main  vessels, 
and  even  dividing  sonw  of  the  Hi)res,  if  not  the  whole,  of  the  iliacus 
internus  and  ])soas  muscles.  The  flaj)  being  raised,  the  ])oint  of  the  knife 
.siiould  then  be  struck  against  the  head  of  the  bone,  so  as  to  divide  the 
anterior  part  of  the  capsular  ligament  and  any  texture  in  this  situation 
which  may  not  have  been  included  in  the  flap.  To  facilitate  this  part 
of  the  operation,  the  knee  should  be  forcil)ly  depressed  bv  the  assistant 
who  holds  it;  tlie  head  of  the  bone  will  thus  be  caused  to  start  from  its 
socket,  and,  if  the  round  ligament  is  not  ruptured  by  the  force,  a  slight 


Furneaux  Jordan's 
method  of  ampu- 
tation at  the  hip- 
joint. 


854  OPERATIVE  SURQERY. 

touch  with  the  edge  of  the  knife  will  cause  it  to  give  way.  At  this  period 
depression  being  no  longer  reipiircd,  the  assistant  should  bring  the  head 
of  the  femur  a  little  forward,  to  allow  the  knife  to  be  slipped  over  and 
l)eliindit;  it  should  then  be  carried  downward  and  backward,  so  as  to 
form  a  Hap  somewhat  longer  than  that  in  front,  the  last  cut  completing 
tlie  separation  of  the  limb. 

Thv  mn(jlv-fl(tp  mcfhod  admits  of  very  ra]>id  ])('rf(irmance.  The  fol- 
lowing are  the  several  steps:  The  patient  lying  u]»on  the  edge  of  the 
table,  the  hip  projecting,  the  artery  is  compressed  upon  the  horizontal 
branch  of  tiie  pubis  ;  tiie  o])erator  then  takes  a  position  on  the  outside 
of  the  limb  (the  left),  which  is  separated  from  the  other  and  slightly 
flexed  on  the  pelvis,  and,  raising  the  soft  parts,  which  cover  the  anterior 
face  of  the  limb,  enters  u  very  long  doul)le-l)laded  knife  midway  i)e- 
tween  the  great  trochanter  and  the  anterior  superior  sjiine  of  the  ilium, 
directing  it  at  first  slightly  from  below  upward  and  from  without  inward, 
so  as  to  reach  the  head  of  the  femur  and  open  the  capsule  of  the  joint ; 
he  now  elevates  the  handle  and  carries  the  knife  in  a  proper  direction, 
the  point  emerging  about  an  inch  below  and  in  front  of  the  tuberosity 
of  the  ischium  ;  the  knife  is  then  carried  downward  along  the  anterior 
surface  of  the  bone,  and  a  large  semilunar  Haj)  is  made,  extending  nearly 
half  the  length  of  the  thigh,  or  six  inches:  care  should  l)e  taken  that  the 
Hap  is  as  long  on  the  inside  as  on  the  outside  :  an  assistant  raises 
the  flap,  at  the  same  time  compressing  the  artery  which  it  contains ; 
the  knife  is  now  applied  to  the  capsule,  which  is  divided  close  to  the 
acetabulum,  as  if  about  to  cut  across  the  middle  of  the  head  of  the 
fenuir  and  at  least  half  of  its  circumference  ;  the  limb  is  then  abducted 
to  luxate  the  head  of  the  bone,  the  knife  passed  l)ehind  it,  and  the  soft 
parts  on  the  posterior  portion  of  the  limb  divided  as  in  the  circular 
operation. 

Lateral  flaps  (Fig.  411)  are  made  as  follows:  The  patient  must  be 
laid  upon  his  back  with  the  tuberosities  of  the  ischia  pn  jecting  slightly 
beyond  the  edge  of  the  bed  and  the  limb  held  in  a  position  lietween 
abduction  and  adduction.  Then,  having  determined  l)y  anatomical  rules 
the  anterior  and  external  side  of  the  articulation,  the  operator,  holding 
perpendicularly  a  long  double-edged  knife,  introduces  it  at  this  point 
with  its  lower  edge  looking  downward  toward  the  great  trochanter.  As 
the  point  of  the  knife  enters  it  should  be  carried  around  the  head  of 
the  femur  on  its  outer  side,  whilst  its  handle  is  inclined  upward  and  out- 
ward and  pushed  steadily  on  in  this  direction,  so  that  it  ])erforates  the 
integuments  a  few  lines  below  the  tuberosity  of  the  ischium.  While 
this  is  being  done  an  assistant  grasps  the  tissues  over  the  trochanter 
and  carries  them  outward  in  order  to  assist  in  the  formation  of  the 
external  fla]),  and  the  knife  is  carried  dowuM'ard  and  outward  with 
a  slightly  sawing  motion,  around  the  great  trochanter  and  along  the 
fenuir,  cutting  out  a  flap  from  three  to  four  inches  in  length.  The  first 
flap  being  thus  made,  the  operatcn',  grasping  the  tissues  on  the  inside  of 
the  thigh  and  carrying  them  inward,  introduces  the  knife  below  the  head 
of  the  femur  and  in  the  inner  side  of  its  neck,  holding  it  in  a  perpen- 
dicular position.  As  it  enters  the  point  of  the  knife  should  pass  around 
the  neck  of  the  femur  and  come  out  at  the  lower  angle  of  the  wound 
already  made,  without  coming  in  contact  with  the  bones  of  the  pelvis ; 


AMPUTATIOX. 


855 


it  is  then  carried  downward  along  the  femur  and  avoiding  the  lesser 
trochantei",  so  as  to  make  an  internal  flap  of  the  same  length  as  the 
external.     The  flaps  being  drawn  aside  by  the  assistants  and  the  arteries 

Fig.  411. 


Amputation  at  the  hip-joint  by  external  and  internal  flaps  (T.  Bryant). 

tied,  the  surgeon  grasps  the  femur  with  his  left  hand,  and,  holding  the 
knife  perpendicularly  on  the  inner  side  of  the  head  of  the  bone,  cuts  the 
capsular  ligament  without  attempting  to  penetrate  the  articidation.  The 
joint  being  opened,  the  disarticulation  is  concluded  by  cutting  the  fibrous 
and  mu.scular  tissues  which  remain. 

Double  flapH,  long  anterior  and  short  posterior,  give  good  results 
(C.  Heath).  The  surgeon  inserts  the  point  of  the  knife  between  the 
spine  of  the  ilium  and  the  trochanter  major,  and  carries  it  across  the 
thigh,  as  near  as  may  be  to  the  head  and  neck  of  the  femur,  until  the 
point  appears  on  the  inside  near  the  scrotum,  which  should  have  been 
previously  drawn  away.  The  knife  is  tt)  cut  slowly  downward  to  make 
a  flap,  under  which  an  assistant  inserts  his  four  lingers  in  order  to  be  able 
to  grasp  the  flap  and  aid  in  compressing  the  principal  artery  as  the 
operator  completes  the  flap,  which  should  be  a  large  one.  The  assistant 
h(jlding  up  the  flap,  the  surgeon  cuts  the  attachment  of  the  gluteus  medius 
muscle  from  the  upper  edge  of  the  trochanter  if  it  has  not  been  already 
done,  opens  the  capsular  ligament  of  the  joint,  and  divides  the  ligamcn- 
tum  teres.  The  head,  of  the  bone  can  then  be  readily  withdrawn  from 
the  acetabulum.  The  knife,  being  placed  behind  the  head  of  the  bone 
and  the  trochanter,  should  be  carried  obliquely  downward  and  backward 
so  as  to  form  a  shorter  flap  behind  than  Mas  made  before. 

The  bloodless  amputation  of  Wycth  is  described  bv  him  as  follows  : 
"  1.  With  the  jiaticnt  in  the  usual  position  for  a  hiji-joint  amputation, 
the  limb  should  Ix-  cin]>ticd  of  blood  either  by  elevatit)n  of  the  foot  and 
lowering  of  the  trunk,  or  l)y  the  Esmarch  bandage  applied  from  the  toes 


85G 


OPERATIVE  SURGERY. 


to  the  trunk.  Under  certain  conditions  the  bandage  can  be  only  partially, 
or  may  be  not  at  all,  applied,  ^\'hen  a  tmnor  exists  or  when  sejjtic  infil- 
tration is  present,  pressure  should  only  be  exercised  not  quite  to  the  dis- 
eased portion,  for  fear  of  driving  septic  matter  into  the  vessels.  After 
injuries  attended  with  great  destruction,  crushing,  or  pulpification,  of 
course  tlie  Esmarcli  Itandage  is  not  applicable,  and  one  must  trust  to 
elevation  to  save  as  much  blood  as  possible. 

"  2.  While  the  member  is  elevated,  or  before  the  Esmarch  bandage  is 
removed,  the  rubber-tubing  constriction  is  applied. 

"The  object  of  this  constriction — and  it  is  the  chief  point  in  the 
method — /.s  the  absolute  occlusion  of  every  vessel  ett  the  level  of  the  hijj- 

FiG.  412. 


The  needles  and  constrictor  applied:  circular  and  longitudinal  incisions  for  skin  flap. 


joint  sf(feli/  above  the  field  of  operation,  permittiur/  the  clisarticulatio)i  to 
be  completed  and  the  vessels  secured  before  the  touruiepiet  is  removed. 

"To  prevent  any  possibility  of  the  tourniquet  slipping,  I  employ  two 
large  mattress-needles  or  skewers  about  three-sixteenths  of  an  inch  in 
diameter  and  ten  inches  long,  one  of  which  is  intniduced  one  inch  below 
the  anterior  superior  spine  of  the  ilium  and  slightly  to  tlie  inner  side  of 
this  prominence,  and  is  made  to  traverse  superficially  the  nmscles  and 
fascia  on  the  outer  side  of  the  hip,  emerging  on  a  level  with,  and  about 
three  inches  from,  the  point  of  entrance.  The  point  of  the  second 
needle  is  made  to  enter  one  inch  below  the  level  of  the  crotch  internally 
to  the  saphenous  opening,  and,  passing  squarely  through  the  adductors, 
comes  out  an  inch  below  the  tuber  ischii.  The  points  are  at  once 
shielded  by  l>its  of  cork  to  prevent  injury  to  the  hands  of  the  operator. 
No  vessels  are  endangered  by  these  skewers.  A  piece  of  strong  white- 
rubber  tube,  half  an  inch  in  diameter  and  long  enough  when  tightened 
in  position  to  go  five  or  six  times  around  the  thigh,  is  now  wound  very 
tightly  around  and  above  the  fixation  needles  and  tied.  If  the  Esmarch 
bandage  has  been  employed,  it  is  now  removed.  Lanpliear  succeeded  in 
holding  the  constriction  in  place  with  only  one  (the  outer)  needle. 
Deaver  was  equally  successfnl  in  holding  the  tubing  well  up  by  two 
strips  of  roller  bandage,  one  before  and  one  behind,  held  by  an  assistant, 
and  thus  dispensing  with  the  needles.     Since  the  needles,  are,  however, 


AMPUTATIOy. 


857 


ahsolutelv  safe,  easy  to  obtain,  and  entirely  out  of  tlie  way,  lie  does  not  see 
any  benelit  to  be  derived  from  their  disuse.  On  the  contrary,  he  would 
beafraid  to  operate  without  them.  As  the  pressure  of  the  constricting 
rubber  is  considerable,  they  should  be  strong.  Bristow  states  that  ou 
one  occasion  a  skewer  of  inferior  quality  gave  way,  and  hemorrhage 
was  narrowly  averted. 

"  3.  In  tlie  formation  of  Haps  the  surgeon  must  be  guided  by  tlie  con- 
dition of  tlie  parts  within  the  held  t>f  operation.  When  permissil)le  the 
following  method  seems  ideal :  About  six  inches  below  the  tourniquet  a 
circular  incision  is  made,  and  this  is  joined  by  a  longitudinal  incision 
commencing  at  the  tourniquet  and  passing  over  the  trochanter  major. 
A  cuff  tiiat  includes  the  subcutaneous  tissues  down  to  the  deep  fascia  is 
dissected  off  to  near  the  level  of  tlie  trochanter  minor.  At  about  the 
level  of  the  trochanter  minor  tlie  remaining  soft  parts,  together  with  the 
vessels,  are  divided  down  to  the  bone  by  a  circular  cut,  and,  in  order  to 
facilitate  the  search  for  the  vessels,  the  soft  parts  are  rapidly  removed 
from  the  femur  for  several  inches  below  the  line  of  the  divided  muscles. 
At  this  stage  of  the  operation  the  larger  vessels,  veins  as  well  as  arteries, 
should  be  tied  with  good-sized  catgut.     Now  leave  the  entire  extremity 

Fifi.  41  s. 


Cuff  iif  skin  and  subcutaneous  fat  turned  baek.niuselcs  divirterl  at  level  of  small  trochanter,  bone 
partly  stripped,  and  lar^'e  vessels  exposed  for  deligation. 

intact  and  use  the  full  length  of  the  limb  as  a  lever  in  dislodging  the 
head  of  the  bone.  When  tlie  larger  and  easily-recognized  vessels  have 
been  secured,  the  muscular  attacliments  to  the  u})per  extremity  of  the 


858  OPERATIVE  SURGERY. 

bone  are  lifted  off  with  scissors  or  knife,  keeping:;  along  very  close  to  the 
hone.  Holding  the  soft  ])arts  away  with  retractors,  the  eapsnlar  liga- 
iiU'iit  is  exposed  and  divided  in  its  cinnunfcrence.  Forcible  elevation, 
abduction,  and  adduction  of  the  thigh  permit  the  entrance  of  air  into 
the  socket,  and  at  the  same  time  rnpture  the  ligamentum  teres,  and  the 
disarticulation  is  thus  easily  and  rapidly  effected.  If,  now,  the  tourni- 
quet be  carefully  and  gradually  loosened,  each  bleeding  jioint  may  be 
determined,  and  the  force])s  applied  as  required  initil  the  tul)e  is  entirely 
removed.  tShonld  any  diiKeulty  be  encountered  in  the  effort  at  enuclea- 
tion (which  is  scarcely  possible),  the  same  precaution  in  securing  all 
bleeding  points  sliould  be  exercised  in  removing  the  tourniquet,  and 
enucleation  completed  with  the  tourniquet  out  of  the  way. 

"4.  In  the  closure  of  the  wound  silkworm  gut  is  preferred  for  suture 
material,  and  one  good-sized  rubber  drain  from  the  acetabulum  out  at 
the  most  dependent  part  of  the  wound.  When  by  reason  of  the  prox- 
imity of  a  neoplasm  or  the  destruction  of  the  parts  by  accident  or  disease 
this  ideal  method  is  not  practicable,  any  modification  may  be  jiractised, 
preference  being  given  to  the  incision  that  keeps  farthest  from  the  tumor 
or  gives  the  healthiest  flaps.  When  there  is  not  sufficient  material  for 
perfect  closure,  it  is  even  safer  to  err  on  the  side  of  an  unclosed  wound 
and  trust  to  granulations  or  grafting  for  ultimate  closing  of  the  wound. 
When,  by  reason  of  severe  hemorrhage  before  operation,  or  when  from 
any  pathologic  ansemia  or  condition  of  weakness,  the  operation  should 
be  rapidly  completed  and  the  small  amount  of  blood  that  will  necessarily 
be  lost  from  capillary  oozing  should  be  saved,  sutures  of  silkworm  gut 
should  be  rapidly  introduced,  the  wound  jiacked  with  hot  sterilized,  plain 
gauze  (not  iodoform  or  bichloride  gauze),  and  the  sutures  temjtorarily 
tightened  for  snug  compression  of  the  wounded  surfaces.  This  packing 
at  once  controls  all  oozing,  and  can  be  removed  in  from  twenty-four  to 
forty-eight  hours  after  reaction,  and  tlic  sutures  finally  secured." 

Accidents  ■which  may  Occub  during  an  Amputation. 

Shock,  a  distnrliance  or  paralysis  of  nerve-centres,  is  liable  to 
supervene  toward  the  close  of  an  operation,  especially  on  a  sudden  loss 
of  blood,  when  the  operator  is  least  prepared  to  encounter  so  formidable 
a  complication.  In  general,  it  is  remarkable  how  little  impression  is 
produced  by  even  the  most  severe  operations,  and  hence  the  surprise 
which  the  discovery  of  the  ]>resencc  of  shock  creates.  The  patient  often 
passes  suddenly  from  a  state  of  jn-oper  anaesthesia,  and  without  any  ad- 
ditional ansesthetic,  to  a  condition  of  more  or  less  profound  shock. 
There  is  no  warning  of  its  approach,  and  the  first  impression  is  that  too 
much  of  the  anaesthetic  has  been  given.  This  is  not  narcosis  from  ana3s- 
thesia,  but  shock.  The  degree  of  jn-ostration  depends  somcMhat  upon 
the  previous  condition  of  the  patient  and  tlie  nature  of  the  disease,  but 
more  markedly  upon  the  degree  of  shock  from  the  injury  wliich  gave 
rise  to  the  operation,  the  amount  of  blood  lost,  and  the  length  of  the 
operation.  The  bodily  tejuperature  and  pulse  are  the  best  guides  to  de- 
termine the  severity  and  danger  of  shock,  and  ought  to  be  noted,  first, 
before  the  operation,  and,  second,  during  and  after  the  operation  :  vari- 
ations not  accounted  for  by  obvious  causes  will  indicate  the  effect  of  the 


ACCWESTS   WHICH  MAY  OCCUR  DVRINO  AN  AMPUTATION.      859 

operation,  and  often  give  timely  warning  of  impending  danger.  In  an 
average  of  cases  of  operations  recoveries  liave  a  fall  of  temperature  of 
less  than  one  dejrree,  and  deaths  of  more  than  three  deiirees  ;  a  fall  liddw 
97°  F.  is  very  critical,  but  recoveries  exceptionally  occur.  When  the 
condition  of  the  patient  or  the  symptoms  indicate  a  susceptibility  to 
shock  jn-eventive  measures  should  be  adopted.  One  of  the  most  simj)le 
and  efficacious  is  the  repeated  administration  of  brandy  or  whiskey  sev- 
eral hours  preceding  the  operation.  An  ounce  of  whisk<y  in  six  or  eight 
ounces  of  hot  milk  given  ten  hours  before  the  operation,  and  rejicated 
once  or  twice  at  two  hours'  interval,  unless  the  signs  of  intoxication 
become  very  manifest,  will  often  secure  a  full  pulse,  allay  all  previous 
fear,  and  render  the  patient  so  susceptible  to  the  antesthetic  that  but  very 
little  will  be  required.  Shock  is  qnite  impossible  under  such  circum- 
stances even  if  there  is  a  sudden  loss  of  blood.  Tlie  effects  of  this 
stimulation  continue  often  forty-eight  hours  or  more,  and  thereby  pre- 
vent secondary  shock  and  depression.  Opium  or  a  hy])odermic  injec- 
tion of  morphia  and  atropia  before  the  operation  tends  to  protect  the 
heart  and  nervous  system  from  depression.  A  cup  of  hot  and  strong 
cotfee  an  hour  or  more  before  the  operation  is  a  simple  and  useful  remedy 
against  the  depression  caused  by  ether  ansesthesia. 

St/ncope  may  be  regarded  and  treati'd  as  an  early  stage  of  collapse. 
These  conditions  differ  only  in  degree  and  duration.  In  the  former  the 
crisis  is  more  ra])id,  and  in  the  latter  the  effects  are  more  extensive  and 
profoiuid.  The  symptoms  are  pallor,  sighing  respiration,  feeble  pulse, 
and  other  signs  of  great  prostration.  The  indications  of  treatment  are 
to  arouse  the  nervous  system  by  stimulation.  Place  the  head  low  ;  apply 
vapor  of  ammonia  cautiously  to  the  nostrils;  give  brandy  l>y  hypo- 
dermic injection  or  by  tlie  mouth  or  rectum  ;  apply  external  heat  to  the 
whole  body,  and  by  cloths  wrung  out  of  hot  mustard-water  over  the 
region  of  the  heart  and  stomach. 

Collapse  may  rapidly  succeed,  with  cold,  clammy  moisture  of  skin, 
and  often  distinct  droj)sof  sweat  ujion  the  brow,  shrunken  and  contracted 
features,  reduced  bodily  temperature,  almost  imperceptible  and  often 
irregular  pulse,  short  and  feelile  or  ])anting  resjiiration.  To  the  treat- 
ment of  shock  add  hypodermic  injections  of  brandy,  gss  to  ,^j,  repeated 
every  five  minutes,  in  the  arms;  or  ether,  10  to  30  minims,  every  ten 
minutes;  strychnia,  gJj^ grain  ;  or  weak  liquor  ammonise,  5  to  10  minims, 
may  be  injected  into  the  veins  ;  large  hot-water  enemata  should  be  given 
witli  the  preceding  remedies.  Electricity,  applied  to  the  regit)n  of  the 
heart,  sliould  be  used.  .Vs  the  most  unfavorable  cases  will  frequently 
recover  if  energetically  treated,  the  efforts  at  restoration  should  not  be 
relaxed  until  recovery  is  secure  or  death  has  occurred.  If  reaction  be- 
gin, stimulation  should  in  part  give  place  to  nutrition  ;  the  patient  must 
remain  in  the  Jiorizontal  position  ;  beef-juice,  with  brandy,  should  be 
given  at  first,  and  hot  coffee  and  milk  should  soon  be  added,  yubcuta- 
neous  injections  of  morphia  are  very  important  in  securing  rest  and 
quiet,  or,  if  the  morpiiia  t'annot  be  taken,  hyoscyamus  may  be  combined 
or  substituted.  Finally,  tincture  of  digitalis  may  be  required  if  reaction 
is  delayed,  in  10  to  20  minim  doses.  External  heat  is  always  to  be 
applied  to  the  whole  body,  and  (-loths  wrung  out  of  hot  water  over 
the  stomach  and  heart ;  friction  of  the  limbs  may  be  usefully  added. 


8G{) 


OJ'i:i!.lTIVE  SURflERY. 


Anannid  may  occur  from  the  loss  of  blood  and  ho  tlic  cause  of  col- 
lapse. To  the  former  treatment  must  now  he  addetl  positicju  ol'  the  l)o<ly 
to  secure  the  flow  of  hlotid  fo  the  head  and  heart,  as  partial  inversion; 
add  to  this  bandaginjj  of  the  limbs  from  their  extremities  toward  tlie 
trunk.  If  the  aiiiiemia  is  extreme,  transfusion  should  be  promptly  re- 
sorted to  or  the  re-injeetion  of  the  blood  collected  durint;'  the  oj)eration. 


Compensative  Appliances. 

The  application  of  artificial  limbs  to  su])])lement  the  losses  occasioned 
by  amputation  must  be  reganled  as  the  higliest  expression  of  mechanical 
art.     The  perfection  of  the  mechanism  of  these  appliances  when  ])ro- 

duced  by  skilled   lal)or  is  not  excelled  in  any 
FiG^414.  branch  of  human  invention.     Hands  and  (trms, 

feet  and  legs,  may  now  be  obtained  M'hieh  are 
scarcely  less  useful,  and  are  often  even  more 
ornamental,  than  the  original  limbs.  And 
these  ajipliances  are  now  within  the  reach  of 
the  most  Jnniible  person.  '^Die  surgeon  can 
no  longer  io;nore  these  facts  and  discriminate 
between  the  rich  and  poor  man's  stuni])S, 
nor  can  the  selection  of  the.se  appliances 
longer  be  left  to  the  patient  himself,  who  i.s 
liable  to  be  imposed  upon  by  mere  manufac- 
turers having  no  ade(piate  knowledge  of  the 
proper  functions  of  the  apparatus  which  they 
are  re(|uired  to  sujiply.  It  not  unfrequently 
ha])}K'ns  that  the  surgeon  does  not  so  fully 
unilerstand  the  mechanism  of  these  ap])lianees 
as  to  be  qualified  to  advise  in  their  selection. 
Such  ignorance  implies  also  a  want  of  good 
juilgment  in  the  formation  of  the  stump  to 
\\  liicli  the  appliance  is  to  be  adjusted,  and  has 
received  judicial  condemnation.  The  impoi't- 
ant  principle  to  be  constantly  borne  in  mind 
in  adapting  stumps  to  artificial  limbs  is  the 
necessity  of  adecpiate  leverage  and  a  well-  com- 
posed and  compact  covering  (E.  D.  Hudson). 
The  finfferi<,  individually  or  as  a  group, 
may  be  supplied  with  apparatus  which  admits 
The  fingers  should  be  so  placed  and  moved  as 
to  enable  the  normal  thumb  to  oppose  each  one  at  all  of  its  articulations, 

and  when  the  fingers  are  closed 
the  thumb  should  be  in  position 
to  close  over  the  first  and  second. 
If  the  thumb  alone  is  lost,  the 
substitute  should  be  adapted  to 
ojipose  the  fingers  (Fig.  415). 
If  the  thuml)  and  forefiuffer  are 


Apparatus  for  useless  elbow, 

of  seizing  and  grasping, 
able  the 

Fig.  415. 


Fig.  416. 


Apparatus  for  fingers. 


supplied,  they  must  be  in  a  state  of  opposition  for  the  purpose  of  grasp- 
ing, but  the  latter  must  be  susceptible  of  easy  extension  (Fig.  416). 


COMPENSATIVE  APPLIANCES. 


861 


Fig.  41 


Apparatus  for  hand. 
Fig.  418. 


The  hand  and  forearm  are  best  supplenientcd  when  the  stump  i.s  matle 
above  tlie  wri.st-joint  and  through  the  lower  portion  of  the  shaft  of  the 
uhia  and  radiu.s  :  the  bulbous  extremity  of  the  radius,  when  the  stump 
is  at  the  wrist-joint,  is  not  adapted  to  the  form  of  .socket  of  the  artificial 
limb.  Tlie  position  of  tiie  fore  and  secontl  fingers  and  thumb  should  be 
as  far  as  possible  that  of  opposi- 
tion when  clo.sed.  I'ronation  and 
supination  are  secured  in  the  fore- 
arm, and  the  flexion  and  exten- 
sion of  the  carpus  are  effected  by 
cords  acting'  through  springs  (Fig. 
417).  The  cords  may  be  acted 
upon  by  the  movements  of  the 
opposite  shoulder  (Fig.  418). 

The  spiral  .spring,  i  (Fig.  418), 
draws  the  fingers,  /,  constantly 
toward  the  thumb,  d,  and  retains 
any  article  placed  witliin  tlie  hand 
and  lictwcen  the  thumb  and  fin- 
gers ;  the  hand  may  be  opened  by 
a  motion  of  the  opjiosite  shoulder 
drawing  on  the  shoulder-strap,  m, 
and  cord,  I:,  or  liy  extending  the 
artificial  hand  and  arm  ;  the  fin- 
gers are  constructed  on  the  metal- 
lic bar,  ff. 

The  arm  and  forearm,  with 
the  hand,  are  supplied  in  amputa- 
tions in  the  arm  liy  a])paratus 
which  derives  its  motion  from  the 
stump;  tlie  backward  motion  extends,  and  the  firward  motion  flexes,  the 
joints  of  the  arm  and  forearm.  In  these  cases  the  upper  arm  consists 
of  a  socket  to  receive  the  stump  of  the  limb,  and  is  secured  by  straps 
to  the  person  with  a  certain  degree  of  rigidity ;  the  anterior  and  poste- 
rior tendons  or  rods  have  a  firm  attachment  at  or  near  the  sjioulder,  pass 
along  or  througii  the  uj)per  section,  an<l  are  attached  to  such  |)oints  on 
tiie  forearm  that  as  one  or  the  otlicr  is  tightened  tlie  forearm  is  flexed  or 
extended  ;  in  some  cases  the  oscillation  of  tiie  elbow  articulation  is 
obtained  by  cords  which  have  direct  or  intermediate  attachment  to  the 
forearm  ;  in  others  the  cords  or  bars  move  a  toothed  wheel  which  engages 
a  pinion  on  tlie  elbow  axis  and  gives  motion  to  the  forearm;  the  back- 
ward motion  of  the  stum])  tends  to  strain  the  anterior  tendon,  which  is 
so  connected  to  the  forearm  behind  the  elbow-joint  as  to  extend  tlie  fore- 
arm ;  the  forward  motion  of  tlie  stump  strains  the  jiosterior  tendon  which 
connects  to  tlie  fbrearm  in  front  of  the  articulation,  and  thus  flexes  it 
as  the  stump  is  moved  forward.  These  motions  follow  the  natural  ones; 
as,  for  instance,  in  the  act  of  raising  the  liand  to  the  nioutli  it  is  usual  to 
o.^cillate  the  arm  forward  on  the  shoulder  as  a  ]iivot,  and  l)ackwardly  as 
the  hand  descends  ;  in  tiie  natural  arm  the  pivotal  ]iositioii  of  the  fore- 
arm is  varied  so  as  to  cause  the  arm  to  swing  in  an  arc  wliicli  will  liring 
the  hand  to  the  required  place,  as  the  mouth  ;  in  the  artificial  arm  the 


.\pparatus  for  head  and  arm. 


8G2 


OPERATIVE  SURGERY. 


motion  on  tlie  sluiiiKk'r  is  tlie  generator  of  the  motion  on  the  ell)()\v,  and 
a  certain  amount  oi'iiradicc  and  adjustment  is  required  to  proptn'tion  tlie 
parts  so  tiiat  the  eonsentaneous  aetiim  of  tiie  parts  wliich  ])ri((hic('  the 
compound  motion  may,  witiiout  ap])arent  constraint  or  indecision,  hind 
tlie  hand  at  the  olyect.  When  the  trunk  of  a  person  attbrds  points  of 
attachment  for  the  flexor  and  extensor  straps,  the  motion  of  the  shoulder 
itself  relatively, to  the  thorax,  and  involving  the  clavicle  and  scajiula, 
may  be  matle  to  assist  in  executing  the  motions  required.  The  primary 
motion  of  the  stump  having  been  communicated  to  the  forearm  by  the 
means  described  (or  other  special  devices  which  are  various  and  very 
ingenious),  the  motions  of  the  hand  are  derived  from  that  of  the  fore- 
arm by  means  of  tendons,  slides,  or  other  attachments  (Fig.  419). 


Fig.  419. 


Appfiriitiis  for  forearm  and  arm. 

The  toes  may  l)e  supplemented  by  artificial  means,  but,  in  general,  a 
boot  provided  with  a  heavy  sole  answers  every  purpose  in  progression. 
The  same  is  true  of  am])ntation  of  the  metacarpus. 

The  foot  cannot  be  ad('(jnatcly  substituted  when  the  amputation  is 
below  the  ankle-joint.  The  tarso-metatarsal  and  medio-tarsal  amputa- 
tions do  not  admit  of  useful  artificial  appliances. 

The  ankle-joint  stump  affords  space,  firmness,  and  leverage  for  the 
artificial  foot,  and  should  be  jircferred  whenever  any  considerable  por- 
tion of  the  foot  must  suffer  amputation,  and  whenever  any  of  the  soft 
tissues  of  the  heel  or  beneath  the  malleolus,  or  of  the  dorsum  of  the 
foot,  are  sufficient  to  constitute  cither  a  single 
or  double  flap,  even  if  necessary  to  form  the 
cicatrix  over  the  conical  jiart  of  the  base  of  the 
stump.  The  appliance  should  have  only  flex- 
ion and  extension,  as  the  ankle-joint  (Fig.  420), 
and  flexion  of  the  toes. 

The  leg  stump  may  l>e  formed  at  any  part, 
but   the  apparatus  is  the  same  in   each   case. 

Fig.  420. 


Fig.  421. 


Artificial  foot. 


Artificial  leg. 


COMPENSATIVE  APPLIANCES. 


863 


Fig.  422. 


The  foot  should  be  of  the  same  mechanism  as  in  tlie  aukle-joiut  stump 
— nainely,  a  socketed  axial  bolt  passing  transversely  through  it,  giving 
only  Hexiou  and  extension  (Fig.  421).  The  construction  of  the  leg- 
piece  is  designed  to  give  lateral  support  hx  a  well-sliai)ed  and  fitting 
socket ;  a  thigh-piece  with  joints  in  the  steel  side- 
pieces  is  necessary  to  sustain  the  limb,  and  elastic 
straps  are  sometimes  added  which  are  attached  to 
a  yoke  strap  over  the  shoulder. 

The  kiur-Joinf  rnnpiitdtion  leaves  a  broad,  well- 
covered  stump,  which  readily  takes  direct  support, 
and  iience,  with  a  well-adjusted  a]>j)liancc,  is  ex- 
tremely serviceable.  Tiie  foot-  and  leg-pieces  are 
the  same  as  those  already  given.  The  knee-joint 
may  be  perfect  in  the  motions  of  flexion  and  ex- 
tension, and  the  padded  socket  should  be  exactly 
adapted  to  the  form  of  tiie  stump.  The  thigh 
should  lace  up  in  front,  and  straps  may  be  added 
to  sustain  the  whole  upon  tiie  shoulder.  Tiie 
same  apparatus  is  necessary  when  the  amputation 
is  at  the  point  of  election,  for  by  flexion  of  the 
short  stump  the  hearing  is  taken  on  the  condyles 
of  the  femur  in  the  same  manner  as  in  knee-joint 
amputation. 

The  (hi(/h  ampufafion  rcipiircs  a  socket  extend- 
ing to  the  hip,  with  bands  attached  which  may 
be  applied  over  the  slioulder  to  support  the  appa- 
ratus. The  construction  of  other  parts  is  the 
same  as  in  amputation  at  tiie  knee.  In  cases  of 
double  amputation  tiicse  appliances  may  be  adapted  to  both  legs,  so  that 
the  individual  will  liave  good  motion  (Fig.  422). 

Tlie  hip-joint  dii<iuiicidation,  though  the  severest  form  of  mutilation, 
admits  of  the  application  of  a  useful  limb.  The  principles  governing 
the  construction  of  tlie  artificial  limb  have  been  stated  as  follows:  The 
position  and  size  of  tiie  tulierosity  of  the  ischium,  tiie  thickness  and  the 
elasticity  of  tlie  tissues  wiiicli  cover  it,  the  very  great  density  of  the 
skin,  render  this  region  very  appropriate  for  the  support  of  the  weiglit 
of  the  body.  It  is  equally  well  adapted  to  transmit  it,  and  a  proper 
regard  for  tliis  governs  tlie  prothcsis,  and  should  also  regulate  the  ope- 
rative procedure.  Nevertheless,  however  fortunately  arranged  the  tulie- 
rosity  of  tlie  iscliium  seems  to  he,  it  forms,  in  tlie  case  of  tlie  loss  of  a 
lower  exti'eniity,  a  very  narrow  I^ase  of  support  either  for  standing  or 
walking  ;  it  is  not  sufBciently  prominent  to  allow  us  to  attacii  tlio  arti- 
ficial limb  ;  it  is  immovable,  and  consequently  incapable  of  communicat- 
ing movement ;  no  natural  intermediate  substance  does  effectually  deaden 
the  shock  caused  by  tjie  artificial  limb  coming  in  contact  witli  tlie  ground. 
In  the  normal  condition  tlie  lower  extremities  serve  as  a  counter-balance 
for  the  u])pcr  jiart  of  the  body  and  broaden  its  seat.  The  coxo-femoral 
disarticulation  iiaving  been  performed  on  one  side,  the  body  ceases  to  lie 
balanced,  and  rests  merely  on  a  bony  protuberance — large,  it  is  true,  but 
convex,  and  merely  touching  the  plane  of  supjjort  by  a  single  point,  and 
a  simple  keel  adjusted  to  tliis  tuberosity  would  leave  the  patient  in  con- 


Artinr'iiil  ]<%s 


imbs. 


864  OPERATIVE  SURGERY. 

tinual  vacillation.  Nature  has  admiral liy  arranged  that  the  weight  of 
the  body  pass  in  a  straight  and  central  line,  because  there  are  distributed 
about  it  contractile  agents  which  maintain  the  equililjrium  ;  but  we  are 
de])rived  of  these  remai'kable  agents,  antl  in  order  to  suj)j)ly  the  mechan- 
ism of  tlie  natural  limb  it  is  necessary  that  the  means  of  prothesis 
embrace  the  whole  space  (occupied  by  tliem.  Now,  tiie  space  rccpiircd 
for  the  attachment  of  tlie  artificial  limb  is  not  reduced  to  the  cylindrical 
circumference  of  the  thigh ;  it  embraces  the  surface  of  the  pelvis,  to 
which  are  inserted  the  muscles  which  while  standing  or  walking  assure 
a  normal  harmony  between  the  j)elvic  bones  and  the  fenuir. 

The  a])])aratus  made  in  accordance  with  these  principles  consists  of  a 
gutta-percha  bonnet  covering  the  entire  region  of  the  stump,  and  re- 
tained in  place  by  a  broad  belt  around  the  body.  To  this  bonnet  is 
attached  the  artificial  limb,  by  means  of  a  joint  which  gives  adequate 
motion  for  jji'ogression. 


INDEX. 


ABDOMEN',  shot  wounds  of,  500 
Abdciminal  section    for   sliot  wounds, 
505 

surgery,  anesthesia  in,  660 
Abernethv,  87 
Abscess,  i72,  343 

metastatic,  178,  400 
Abscesses,  bacteria  causing,  308,  309,  310 

expei'imental  jiroduction  of,  280,  303 

secondary  to  typlioid  fever,  321 
Absorbent  dressings,  692 
Accidents  during  operation,  858 
A.  C.  E.  mixture,  655,  657 
Acetabulum,  fracture  of,  572 
Acliley,  H.  A.,  143 
Acrel,  O.,  127 
Acromion,  fracture  of,  583 
Actinomyces,     association    with     pyogenic 
cocci,  302 

characters  of,  332 

in  tlie  intestine,  265 

in  lladura  disease,  334 

in  tlie  mouth,  260 

pyogenic  capacity,  309,  334 

in  vegetable  grains,  276,  334 
Actinomycosis,  353 
Actual  cautery,  742 
Acupressure,  741 
Adams,  K.,  100 
Aetius,  31 
Age,  influence  in  infections,  303 

influence  of.  in  operations,  730 
Agnew,  D.  H.,  140 

Agnew's  method  for  fracture  of  patella,  554 
Agucro,  B.  d  ,  69 
Air,  bacteria  of,  276,  679 
Air-embolism,  212 
Air-passages,  bacteria  in,  262 
■Vhmson,  E.,  88 
Mbucasis,  36 
\lcazar,  A.,  00 

■Vlcoholism,  relation  of,  to  infections,  305 
Alexins,  294 

Allis,  on  fractiu-e  lower  end  of  humerus,  587 
Allis's  acupressure  forceps,'  741 

sign,  507  » 

Alumina,  acetate  of,  705 
Annuann,  P.,  60 
Anmion,  P.  A.  von,  120 
Aniicba  coli,  182 

dyseiiteriie,  265,  302 
Amputation,  32,  54,  811 

at  ankle,  842 

of  arm,  848 

Vol.  I. — 55 


Amputation,  Berger's,  833 

Garden's,  849 

Cliopart's,  839 

circular  method,  814 

in  compound  fractures,  527 

double  llaji,  S15 

at  cUiow-joint,  827 

of  Hngers,  817 

flap  method,  60,  67,  814 

of  foot,  834 

of  forearm,  826 

Gritti's,  850 

Guvon's  845 

He/s,  838 

at  hip-joint,  476,  852 

interscapulo-thoracic,  833 

at  knee-ioint,  848 

medio-tarsal,  839 

at  metacarpus,  823 

at  metatarsus,  837 

Pirogoff's,  844 

subastragaloid,  841 

supramalleolai',  845 

Syme's,  843 

tarso-metatarsal,  838 

Teale's,  815 

of  thigh,  850 

of  thumb,  821 

of  toes,  835 

Tripier's,  841 

at  wrist,  825 
Amussat,  J.  Z.,  Ill 
Amyloid  degeneration,  234 
Ana-mia,  relation  of,  to  infections,  296,  304 
Anaerobic  bacilli  in  intestine,  264 
in  pus,  309 
in  the  vagina,  268 
Antesthesia,  137,  645 
Aniesthetic,  61 
Ana'sthetics,  choice  of,  655 

mixed,  055 
Andrv,  N.,  71 
Anel,'  D.,  73 
Aneurism,  33,  37,  52 

ligature  of,  52,  73 

needle,  743 
Ankle,  shot-wounds  of,  478 
Ankle-joint,  amputation  at,  842 

dislocation  of,  636 

resection  of,  796 
Antisepsis,  ](«,  719 
Antiseptic  .solutions,  395 

surgery,  677 

experiments,  300,  301 

865 


866 


INDEX. 


Antiseptics,  683 
Antitoxic  immunity,  295 
Antitoxine  of  tetanus,  431 
Antyllus  on  aneurism,  33 
Aorta,  ligature  of,  762 
Aplasia,  229 

Apparatus,  compensatory,  860 
Aiipoiidicitis,  actinomyces  in,  265 

bacillus  coli  communis  in,  274 
proteus  in,  o22 

predisposing  intiuence  of  obstructions  in, 
297 

pyogenic  cocci  in,  274,  275 
Ariieus,  F.,  68 
Arderne,  John,  61 
Argelata,  Petrus  d'l,  44 
Arm,  amputation  in,  828 

artificial,  861 
Arra_y  surgeons,  78,  79 
Arnaud  de  Ronsil,  73 
Arris  and  Gale  lectures,  64 
Arrow-poisons,  407 
Arrow-wounds,  513 
Arteries,  ligature  of,  742 

torsion  of,  740 
Arterio-sclerosis,  in  relation  to  pyogenic  in- 
fections, 306 
Artery  forcei)s,  739 
Artificial  limbs,  860 
Aseptic  fever,  203,  415,  717 

surgery,  677 

wounds,  bacteria  in,  251,  272,  292 
Astnigalus,  dislocation  of,  640 

fracture  of,  542 

resection  of,  794 
Atheroma  in  ana'sthesia,  657 
Atlee,  J.  L.,  141 

W.  F.,  113 

W.  L.,  141 
Atria  of  infection,  279,  283,  339 
Atrophy,  229 

after  fracture,  535 
Auricular  artery,  posterior  ligature  of,  753 
Austria,  history  of  surgery  in,  79,  117 
Auto-infection,  268,  272,  274,  305 
Autopsies,  pyogenic  bacteria  found  at,  311 
Avian  tuberculosis,  bacillus  of,  330 
Avicenna,  36 

Avulsion  of  phalanges,  602 
Axillary  artery,  ligature  of,  756 
Ayur-\'eda,  25 

BACILLUS  aerogenes  capsulatus,  322 
found  at  autopsies,  311 
chtiracters  of,  322 
in  intestine,  265 
pathogenic  manifestations,  322 
anthracis,  331 

antagonized  by  other  bacteria,  291 

characters  of,  331 

dosage,  288 

elimination  by  secretions,  285,  286,  288 

enhances  virulence  of  micrococcns  lan- 

ccolatus,  291 
germination  of  spores  in  intestine,  264 
infection  by  feeding,  281 
infection  through  lungs,  282 


Bacillus  anthracis,  in  hides,  wool,  etc.,  276 
not  absorbed  from  suppurating  wounds, 

297 
placental  transmission  of,  307 
predisposition  to,  303,  304 
rapidity  of  absorption  from  fresh  wounds, 

284,  300 
virulence  for  different  races  of  animals, 
303 
liuccalis  maximus,  258 
capsulatus  of  Pfeiffer,  262 
of  chicken  cholera,  placental  transmission 

of,  307 
coli  comnuniis,  in  abscesses,  310 
in  ap]iendicitis,  274 
in  the  bile,  265 

cause  of  hepatic  neuroses,  286 
charactei's  of,  320 
conditions  of  inviision,  274 
in  the  conjunctiva,  256 
frequency  of  presence  in  organs  at 

autojjsy,  311 
in  the  mouth,  258 
outside  of  the  body,   253,   267,  276, 

320 
pathogenic  action,  274,  286,  302,  309, 

321 
in  peritonitis,  274 
on  the  skin,  253,  267 
in  the  stomach  and  intestine,  264,  274, 

320 
in  the  lu-ethra,  267 
virulence  of",  271,  291,  321 
in  wounds,  253,  274,  321 
crassus  s])utigenus,  258 
dij)htheria>,  characters  of,  322 

destruction  in  the  throat  liy  chemical 

disinfectants,  3(11 
in  fibrinous  rhinitis,  262 
on  the  hair  of  nurses,  254 
in  the  healthy  throat,  260 
modification  of  virulence  by  other  bac- 
teria, 292 
relation  to  xerosis  bacillus,  257 
in  surgical  infections,  323 
of  glanders.   See  Bitfillii>i  Mttllei. 
lactis  aerogenes,  characters  of,  231 
in  c.ystitis,  267 
in  the  nose,  262 
relation  to   bacillus  coli   communis, 

274,  321 
in  the  stomach  and  intestine,  264 
lepra?,  characters  of,  330 

spores  of,  278,  330 
of  malignant  a'dema,  characters  of,  322 
in  the  intestine,  265 
on  skin  contaminated  with  soil,  253 
in  the  soil,  276 
mallei,  artificial  predisposition  to,  305 
characters  of,  .330 
spores,  278,  330 
of  mouse  septicemia,  dosage,  288 

elimination  by  conjunctiva,  285 
of  oziena,  262 

phlegmones  emphysematosa,  309,  322 
pneumonia^  of  Friedhinder,  antagonism  to 
infection  by  anthrax  bacillus,  291 


INDEX. 


8G7 


Bacillus  pneumonia  of  Friedlander,  elimina- 
tion by  secretions,  285 
on  exposed  surfaces,  275 
in  the  middle  ear,  263 
in  tlie  mouth,  258 
in  the  nose,  261 
pathogenic  manifestations,  275,  309, 

311,  320 
predisposition  to,  304 
relatiim  to  rhinoscleroma  bacillus  and 
otlier  capsulated  bacilli,  262,  320 
prodigiosus,    elimination    by    secretions, 
"  286,  288 
enhances  virulence  of  other  bacteria, 
291,  292 
proteus,  cliaracters  of,  321 

in  decomposing  substances,  276,  322 
enhances  virulence  of  otlier  bacteria, 

291,  305 
on  exposed  surfiices,  275 
in  tlio  intestine,  265 
pathogenic    manifestations,     275,    309, 

311,  322 
varieties — proteus  vulgaris,    mirabilis, 

and  Zenkeri,   321 
pseudo-diplitlieri;e,  257,  260 
pyocvaneus,  in  abscesses,  310 
in  the  air,  277 
cliaracters  of,  320 
elimination  in  secretions,  285 
in  the  intestine,  265,  320 
in  tlie  middle  ear,  263 
|)athogenic  action,  320 
on  the  skin,  253,  273,  320 
in  the  vagina,  269 
in  wounds,  253,  273,  284,  310,  320 
pyogenes  ftetidus,  character  of,  320 
in  intestines,  265 

pathogenic  manifestations,  309,  311, 
320' 
of  rabliit  septicaemia,  dosage,  288 
invasion  from  the  lungs,  282 
not      absorbed      from     suppurating 

wounds,   297 
rapidity    of   absorption    from    fresh 
wounds,   300 
of  rhinoscleroma,  262,  320 
of  smegma,  254,  266,  329 
of  symptomatic  anthrax,  292,  304,  307 
tetaiii,  326,  426 

antitoxic  immunity  from,  295,  328 
in  feces  of  herbivora,  253,  265,  276 
influence  of  association  with  toxic  prod- 
ucts and  other  bacteria,  289,  292 
in  soil,  275 
toxins,  326 

viability  in  dog's  intestine,  276 
tholiieideus,  267 

tuberculosis,  association  irith  streptococ- 
cus pyogenes,  292 
in  bronchial  glands,  283 
characters  of,  240,  329 
ditiercntiation    from    smegma    bacilli, 

254 
in  the  healtliv  nose,  262 
in  milk,  287  " 
in  necrogenic  warts,  276 


Bacillus  tuberculosis,  placental  transmission 
of,  307 
predisposition  to,  302,  305 
prolonged  latency  of,  282 
pyogenic  capacity,  309 
of  tuberculosis  of  fowls,  330 
typhi  abdominalis,  association  with  pyo- 
genic cocci,  291,  292,  321 
cause  of  hepatic  necroses,  286 
cause  of  osteomyelitis  and  periostitis, 

321 
eliiiiiuation  by  secretions,  286,  287 
placental  transmission  of,  307,  308, 
pyogenic  capacity,  309,  321 
resistance,  279,  256,  261 
susceptibility  of  fcetus  to,  308 
vagin;e  of  Doederlein,  268,  269 
xerosis,  257 
Bacteria,  175 

action    of   chemical   disinfectants   on,    in 

wounds,   284,   300 
in  air,  276,  079 

in  aseptic  wounds,  251,  272,  292,  298 
in  the  blood  in  surgical  infectious,  252, 

313 
in  cerumen,  254 
of  the  conjunctiva,  255 
destruction  of,  by  living  cells,  blood,  and 
other  fiui'ds  of  the  body,  256,  260, 
262,  264,  265,  267,  269,  271,  279, 

282,  294,  298,  299,  300,  314 
dosage  and  virulence  of,  288 
elimination  of,  in  secretions,  284 
of  the  genito-urinary  tract,  265 
germinal  and  placental  transmission  of, 

306 
of  the  hair,  254,  278 
within  the  healthy  body,  272 
in  liernial  sacs,  297 
immunity  from,  279,  293 
infecting,  dosage  of,  288 
in  milk,  270 

mode  of  entrance  of  279 
of  the  moutli  and  pharynx,  257 
parasitic,  278 

pathogenic,  spore-forming,  278 
placental  transmission  of,  306 
pyogenic,  308 

rapidity  of  absorption  of,  283,  284,  300 
of  the   respiratory  passages  and   middle 

ear,  261 
saprophytic,  278 
in  secondary  and  mixed  infections,  273, 

283,  "290,  302,  305,  313 
of  the  skin,  250 

of  the  soil,  276 

of  the  stomach  and  intestine,  263 

of  surgical  infections,  morphological  and 

biological  properties  of,  249,  315 
in  the  sweat,  252,  288 
virulence  of,  288 

wound-infection  by,  249,  252,  253,  272, 
275,  292,  298,  309,  324 
Kacterial  association,  290 
Bactericidal  properties  of  bile,  265 
of  blood,  280,  294,  299,  314 
of  gastric  juice,  264 


808 


INDEX. 


Bactericidal   iii'opcrties  of  laclirvrnal  secre- 
tion, "Joti 

of  leucocvtes  and  other  cells,  294,  300 

of  milk,  271 

of  nasal  secretion,  202 

of  saliva,  200 

of  nrine,  207 

of  nterine  secretion,  270 

of  vaginal  secretion,  2(ill 
Bacteriological     examinations    of    surgical 

infections,  value  of,  312 
Bacteriologv,  surgical,  249 
Balassa,  .V.',  124 
Ballingall,  Sir  ( jeorge,  94 
Bandage,  clastic,  737 
Barber  surgeons,  42,  03,  127 
Barbette,  P.,  58 
Bard,  J.,  134 
Barton,  J.  K.,  136 
Baseilhac,  74 
Bass,  H.,  78 
Battns,  C,  58 
Baudens,  J.  B.  L.,  112 
Baum,  W.,  123 
Baynham,  W.,  134 
Bayonet  wounds,  512 
Beaulien,  J.  de,  71 
Beck,  Marcus,  103 
Beckett,  W.,  84 
Bed-sores,  180,  300 
Bee-stings,  408 
Bell,  B.,"  89 
C,  93 
.7.,  89 
Bellingham,  O'Bryen,  100 
Belloqi  J.  L.,  74  ' 
Benedict,  T.  W.  G.,  121 
Benedictus,  Alexander,  45 
Eenevoli,  A.,  81 
Berard,  A.,  110 
Berengarius  C'arpensis,  45 
Berlinghieri,  A.  V.,  117 
Bertrandi,  G.  A.,  81 
Bible,  medicine  of,  19 
Bienaise,  J.,  58 
Bigeloiv,  H.  J.,  138 
Biggs,  IT.  M.,  on  rabies,  433 
Bile,  bacteria  in,  265,  285,  286 
Bilgner,  78 
Bill,  J.  H.,  514 

Billings,  J.  S.,  ou  history  of  surgery,  17 
Billroth,  T.,  126 
Bismuth  subnitrate,  697 
Bites,  spider-,  409 
Bjerkin,  P.  af,  127 
Blackman,  G.  C,  141 
Bladder,  bacteria  in,  267 
rupture  of,  571 
shot-wounds  of,  509 
supra-pubic  puncture  of,  70 
Blandin,  P.  F.,  110 
Blasins,  E.,  120 
Blazina,  J.,  124 
Bleeders,  381 
Blegnv,  N.  de,  58 
Blizarcl,  T.,  101 
W.,  h8 


Blondus,  M.  A.,  45 

Blood,  bacteria  in,  252,  299,  313,  314 

bactericidal  power  .,f,  280,  294,  299,  305, 
314 

coagulation  of,  206 

conveyance  of  bacteria  by,  272,  302,  314 

in  healing  of  wounds,  299 

regeneration  of,  224 
Blood-clots,  healing  by,  526,  715 
Blood-plates,  208 
Blood-pressure,  in  ana?sthesia,  648 
Blood-vessels,  formation  of,  194 
Bloxam's  dislocation  tourniquet,  611 
Blue  pus,  253,  320 

Boeckel's  mctliod  for  excision  of  wrist,  784 
Bond's  splint,  597 
Bone  forceps,  775 

scoop,  778 
Bones,  resection  of,  773 

shot-wounds  of,  459 
Bonnet,  A.,  Ill 
Botallo,  L.,  45 
Bougies,  725 
Boyer,  A.,  105 

Brachial  artery,  ligature  of,  757 
Brain,  abscess  of,  486 

disease,  in  anaesthesia,  657 

shot-wounds  of,  483 
Brainard,  D.,  137 
Brainard's  drill,  538 
Brambilla,  G.  A.,  79 
Brasdor,  P.,  74 
Breast,  excision  of,  67,  710 
Bright's  disease,  in  anesthesia,  061 

in  pvogenic  infections,  306 
Broca,  P'.,  114 
Brodie,  B.,  93 
Bromficld,  W.,  84 
Bronchi,  bacteria  in,  262 
Brown,  J.,  ()7 

Briinninghansen,  H.  J.,  119 
Bruns,  \.  von,  123 
Ernnscbwig,  H.,  53 
Brush-burn,  365 
Bryant's  triangle,  567 
Bnck,  G.,  139 

Buck's  extension  method,  503 
BnfT\'  coat,  198 
Bnjalski,  E.,  128 
Bu'llets,  infected,  276 
Burns,  362 
Burns,  A.,  95 

J.,  94 
Burow's  solution,  697,  705 
Busch,  C.  1).  W.,  123 
Butcher's  saw,  777 

pALCANEITM,  fracture  of,  540 

\j     resection  of,  795 

Calcification,  236 

Callawav's  test,  619 

Callender,  G.  W.,  102 

Callisen,  H.,  127 

Camper,  P.,  80 

Canape,  J.,  51 

Caucrnm  oris,  391 

Caiisulated  bacilli,  262,  320 


IXDEX. 


869 


Carbolic  acid,  705 

Garden's  amputation,  knee,  849 

Cardiac  disease  in  pyogenic  infection,  300 

Carnialt,  W.  H.,  on  septica;mia,  etc.,  383 

Carmicliael,  R.,  99 

Carnocliau,  J.  M. ,  142 

Carotid,  common,  ligature  of,  88,  134,  747 

external,  ligature  of,  749 

internal,  ligature  of,  753 
Carpal  ijones,  dislocation  of,  624 

fracture  of,  (iOl 
Carpue,  J.  C,  92 
Carr's  splint,  597 

Cartilages  of  ribs,  dislocation  of,  G14 
Caseation,  227 
Catarrhal  intlammation,  168 
Catgut,  disinfection  of,  701 
Catlieter  fever,  204 
Catlieters,  725 

lubricants  for,  726 
Caulay,  C,  72 
Cauteries,  742 
Cells,  slumbering,  164 
Cellulitis,  liacteria  of,  310,  311 
Celsus,  29 
Centresome,  219 
Cerumen,  bacteria  in,  254 
Cicatricial  tissue,  193 
Civialc,  J.,  1(18 
Chain  saw,  775 
Cliarethanus,  J.,  56 
Chassaignac,  E.  P.  M.,  113 
Chelius,  M.  .1.  von,  119 
Cheselden,  W.,  83 
Chest,  shot-wounds  of,  495 
Chilblain,  354 

Cliina,  ancient  surgery  of,  28 
Chionyphe  I'arteri,  353- 
Chloroform,  64S 

eliccts  on  nutrition,  665 

mask,  702 
Chondroblasts,  223 
Chopart,  F. ,  75 
Cliopart's  amputation,  839 
Chromatin,  219 
Clark's  extension  method,  589 
Clavicle,  dislocation  of,  614 

fracture  of,  577 

resection  of,  134,  792 
Cline,  H.,  88 
Clociuet,  J.  (x.,  107 
Clou<ly  swelling,  231 
Clove-hitcli,  612 
Clover's  inhaler,  668 
Clowes,  \V. ,  1)3 
Coagulation  necrosis,  214,  227 
Coccyx,  excision  of,  805 
Cock,  K.,  101 
Cogswell,  M.  F.,  134 
Colndieim,  153,  155,  160 
Col  de  Villars,  E.,  73 
Collapse,  859 
Collateral  circidation,  215 
Colles,  A.,  99 
CoUes's  fracture,  595 

law,  99 
Colloid  degeneration,  233 


Colot  family,  48 
Colotomy,  71 
Compression,  digital,  738 
Concretions,  236 
Congestion,  156 
Conjunctiva,  bacteria  of,  255 

disinfection  of,  257 

elimination  of  bacteria  by,  285 
Connective  tissue,  145 
Coimer,  P.  S.,  on  gunshot  wounds,  445 
Constantinus  Africanus,  39 
Contact  infection,  275 
Contusions,  373 
Convalescence,  736 
Cook,  J.,  66 
Cooper,  Sir  Astley,  91 

E.  a,  141 

S.,  92 
Cooper's  method  in  dislocations  of  hip,  630, 
632 
of  shoulder,  619 
Coote,  R.  Holmes,  102 
Coraeoid  process,  fracture  of,  583 
Coronoid  process  of  ulna,  fracture  of,  600 
Corpora  amylacea,  236 
Corrosive  sublimate,  252,  300,  704 
Corsets,  231 
Cortesi,  G.  B.,  57 
Coryza,  bacteria  in,  262 
Costo-sternal  dislocation,  614 
Coulson,  W.,  101 

Councilman,  W.  T.,  surgical  patholog}',  145 
Covillard,  58 
Cox,  W.  S.,  98 
Crampton,  P.,  99 
Cranium,  fracture  of,  22 

shot-wounds  of,  479 
Creolin,  705 
Crepitus,  520 
Crosse,  J.  G.,  98 
Croupous  intlammation,  170 
Crvptogenetic  septico-pva;niia,  283,  298 
Cusack^J.  W.,  100 
Cystitis,  bacteria  in,  267,  274 

pre<lisposing  causes  of,  274,  297 
Czekierski,  J.,  128 

DACA  CHACON,  D.,  69 
Dalecbamps,  J.,  51 
Daniel,  \V.  C,  134 
DaniU'wski  on  intlammation,  183 
Deadrick,  W.  H.,  134 
Dease,  W.,  90 

Decubitus,  360  , 

Defences  against  bacteria,  279 
Defensive  proteids,  294 
Degeneration,  amyloid,  234 

colloid,  233 

fatty,  232 

hyaline,  234 

waxy,  227 
Delirium,  374 
Delitescence,  336 
Dc1]kmIi,  J.  M.,  108 
Dclt.iid,  paralysis  of,  619 
])emarcation,  line  of,  358 
Demme,  11.,  124 


870 


INDEX. 


Denmark,  surgery  in,  126 

Dennis,  F.  S.,  on  fractures,  etc.,  515 

Denonvilliers,  C.  P.,  llo 

Desault,  P.  J.,  74 

Descliainps,  J.  F.,  76 

Deutsclinian,  187 

Diabetes,  1S4 

following  anaesthesia,  664 

relations  to  infection,  305 
Diapedesis,  14M 
DietlenliacI),  J.  F.,  119 
Digbv,  Kenelm,  (i.S 
Digital  comjiression,  738 
Dionis,  P.,  70 
Diphtheria,  antitoxin  of,  295,  329 

bacillus  of     See  Bacillus  Diphlherice. 

secondary  infections  of,  292,  323 

toxins  of,  323 

of  wounds,  324 
Diplococci  in  the  urethra  and  vagina,  266, 

268 
Diplococcus   pneumoniae.      See  Micrococcus 

Lanceolalm. 
Disinfection,  682 

of  mucous  membrane,  257 

of  the  skin,  251,  252 

of  the  vagina,  270 

of  wounds,  284,  300 
Dislocations,  23,  603.    See  also  under  names 

of  bones  and  joints. 
Dissection  wounds,  372 
Dolbeau,  H.  F.,  114 
Dorsalis  pedis  artery,  ligature  of,  773 
Dorsey,  J.  S.,  133 
Dosage  of  infecting  bacteria,  288 
Douglas,  J.,  84 
Dracontiasis,  352 
Drainage,  702 

of  wounds,  369 
Drainage-tubes,  703 

objections  to,  252,  298 
Dressing-rooms,  710 
Dressings,  aseptic,  691 

permanent,  716 
Drill,  Brainard's,  538 
Drills,  777 
Drnitt,  K.,  102 
Dubois,  A.,  105 
Dubovizki,  P.,  129 
Dudley,  K.  W.,  137 
Dugas's  test,  619 
Dumreicher,  J.,  125 
Duodenal  ulcer,  362 
Dupuytren,  G.,  106 
Dupuytren's  splint,  550 
Dust,  bacteria  in,  277 

EAR,  middle,  bacteria  in,  263 
Karle,  Sir  James,  88 
Edinhvn-gh,  history  of  surgery  in,  65,  83,  94 
Elastic  bandage,  737 
Elbow-joint,  amputation  at,  827 

dislocations  of,  621 

resection  of,  786 

shot-wounds  of,  472 
Elimination  of  bacteria,  284 
Embolism,  211 


Embolism,  air,  212 

fat,  21.3,  .532 

jiulmonarv,  534 
Emergency  dressings,  721 
Emigration  of  corpuscles,  148,  162 
Emphysema  in  aniesthesia,  658 
Emphysematous  iihlegmons,  309,  322 
Endocarditis,  in  the  fa'tus   308 

gonococcns  in,  319 

production  of,  302 
English  surgery,  history  of,  60,  81 
Epidermis,  staphylococcus  in,  251 
Epiphyseal  sejiaration,  585 
Epithelioid  cells,  241 
Epithelium,  new  formation  of,  196 
Erysipelas,  418 

neonatorum,  422 

virus,  for  tumors,  423 
Erysipeloid,  zoonotic,  270 
Esmarch's  ehustic  bandage  in  amjiutation 

at  shoulder-joint,  831 
Ether,  646 
Etherization,  667 
Ethyl  bromide,  653 
Ethvlene  bromide,  653 
j;ve",  P.  F.,  141 

Excisions  of  bones  and  joints,  773 
Executioners,  76 
Explosive  zone,  481 
Extension  apparatus,  134,  563 
Exudation,  190 

FABRICIUS  D'AQUAPENDENTE,  56 
Fabricius  Hildanus,  59 
Face,  shot-wounds  of,  487 
Facial  artery,  ligature  of,  750 
Facultative  parasites,  278 
Fieces,  bacteria  of,  264 
Falcutius,  N.,  42 
False  joint,  536 

Farabeuf's  method,  excision  of  upper  jaw, 
810 
snbstragaloid  amputation,  842 
Farkas'  catheter  sterilizer,  726 
Fat-embolism,  213,  532 
Fat-necrosis,  228 
Fatigue,  relation  to  infection,  304 
Fattv  degeneration,  232 
Faudacq,  C,  80 
Fave,  U.  de  la,  73 
Felon,  351 

Femoral  artery,  ligature  of,  767 
Femur,  fracture  of,  558 
of  neck  of,  566 

resections  of,  802 
Fergusson,  Sir  W.,  95 
Ferrius,  A.,  45 
Fever,  199 

aseptic,  203,  415,  717 

irritative,  393 

purulent,  399 

pyaemic,  402 

surgical,  416 

traumatic,  415 
Fibi'in,  161 
Filirin-fermeut,  206 
Fibrinous  intlammation,  169 


IXDEX. 


871 


Fibroblasts,  2-23 

Fibula,  dislocation  of,  636 

fraoture  of,  oW 

resection  of,  797 
Finger-nails,  bacteria  beneath,  251,  253 
Fingers,  amputation  of,  817 

avulsion  of,  602 
Fischer,  (i.,  76 
Fistula  in  ano,  61 
Flies  as  carriers  of  infection,  276 
Fludil,  K.,  68 

Fetus,  infections  of  the,  304,  306,  308 
Follin,  E.,  Ill 
Foot,  amputations  in,  834 

artiticial,  862 
Forceps,  778 
Forearm,  amputation  in,  826 

fractures  of,  5;14 
Foi-ster,  J.  Cooper,  102 
Foster,  W.,  68 
Four  Mastei's,  39 
Fourcrov,  104 
Fracture-box,  544 

Fractures,  515.     See  also  under  names  of 
bones. 

compound,  523 
statistics  of,  529 

gunshot,  459 

non-union  of,  536 

repair  in,  223 

statistics  of,  519 

suppuration  in,  272,  302 

ununited,  seton  in,  132 
Fragosa,  J.,  69 
Franco,  P.,  48 
Freer,  G.,  98 
French  surgery,  history  of,  42,  49,  58,  70, 

104  ■ 
Frere  Come,  74 

Jaccpies,  71 
Fricke,  J.  C.  G.,  121 
Friedlander  bacillus.     See  Micrococcus  Lan- 

crolatns. 
Friedrich  Wilhelms  Institut,  78 
Frost  and  Baitlett,  448 
Frostbite,  355 
Fungus  cerebri,  486 
Furuncle,  252,  280,  350 

GAGO  DE  VADILLO,  P.,  69 
Gale,  T.,  62 
Galen,  30 
Gall-stones,  237 

bacilli  in,  265,  321 
Ganigee,  J.  S.,  99 
(iangrene,  228,  356,  533 

amputation  in,  397 

hospital,  359 

hot,  229 

traumatic,  389 
fiarengeot,  R.  J.  C.  de,  71 
(ias  phlegmons,  309,  322 
Gastric  juice,  germicidal  action  of,  264 
(Jataker,  .T.,  88 
Ciav,  9S 

j.,  101 
Geddiugs,  E.,  143 


Genitals,  shot-wounds  of,  511 
Genito-urinarv  tract,  bacteria  of,  265 

tuberculosis,  246 
Gensoul,  J.,  Ill 
Gerdy,  P.  N.,  109  _ 

(iennan  surgery,  history  of,  52,  54,  76,  117 
Germinal  centres,  221 

infections,  306 
Gersdorfi;  Hans  von,  53 
Gerstcr,  A.  (i.,  antiseptic  surgery,  677 
(Tibsim,  W.,  133 
(iiraldcs,  J.  A.  C.  C,  115 
t4irdner's  telephonic  probe,  451 
(i  landers.     See  Barilhia  Mallei. 
Glaudorp,  M.  L.,  60 
Glands,  regeneration  in,  222 
(ilottis,  u'dema  of,  573 
({luteal  artery,  ligature  of,  764 
Glycogen,  233 
Gonococcus,  267 

associations  of,  302,  319 

charactersof,  319 

dift'erentiation  of,  267 

pyogenic  capacity  of,  309,  319 

iii  vagina,  268,  269,  270 
Gonorrlueal  complications,  319 
Gooch,  B.,  84 
Gordon's  splint,  596 
Gosselin,  A.  L.,  114 
Gouges,  777 
Govrand,  J.  G.  B.,  112 
Graefe,  C".  F.  von,  119 
Gran\ilar  degeneration,  231 
Granulations,  188 
Green,  .J.  II.,  97 
Greenstick  fracture,  517 
Gritti's  amputation,  knee,  850 
Gross,  S.  L).,  139 

S.  W.,  140 
Grossheim,  E.  L.,  121 
Growth,  216 
Giinther,  G.  B.,  123 
Guerin,  J.,  115 
Guersant,  P.  L.  B.,  115 
Guillemeau,  J.,  52 
Guinea-worm,  352 
Gunn,  M.,  142 

Gunshot  wounds,  44,  276,  445,  459 
Gurlt,  statistics  of  fractures,  519 
Guthrie,  G.  J.,  97 
Guy  de  Chauliac,  41 
Guy's  Hospital,  81 

HAARTMAN,  VON,  129 
Habits,  etl(»ct  of,  in  operations,  731 
ILcmatolysis  in  infections,  305 
Hoemopbilia,  3S1 
Hiemostasis,  379 
Hair,  bacteria  on,  254,  278 
Hair-follicles,  penetration  of  pyogenic  cocci 
into,  281 
staphylococcus  epidermidis  albus  in,  251 
Halle,  J.,  63 
Haller,  A.  von,  77 
Halsted's  .sliding  splint,  545 
Hamilton,  F.  H.,  139 
Hamilton's  double  splint,  564 


872 


INDEX. 


Hamilton's  mctliuil  for  fracture  of  palilla, 

554 
IlaiKock,  II.,  101 
Hand,  amputation  of,  821 

artilicial,  XdO,  Stil 
llariils,  disinfection  of,  086 
llan"-li|i,  (iO 
Harrison,  K.,  100 
Hawkins,  Sir  Cffisar,  88 

C.  IL,  98 
Hay  ward,  G.,  143 
Head,  sliot-wounds  of,  479 
Head-tetauus,  428 
Healing  by  second  intention,  368 
Heart,  abscess  in,  405 

shot-wounds  of,  499 
Heart  diseiise  in  ana?sthesia,  657 
Heat-production,  199 

Heath's  metliod,  amputation  of  hip-joint,  855 
Heine,  C.  W.  von,  124 

J.  von,  124 
Heister,  L.,  77 
Heliodorns,  30 
Heloderma  suspectum,  412 
Hemorrhage,  32,  378 

prevention  of,  737 

secondarv,  457,  486 
Hendriksz,"P.,  116 
Ilennen,  J.,  94 
Hernia,  femoral,  58 

strangidated,  bacteria  iu,  297 
Herophilus,  28 
Herpetic  diseases,  186 
Herrmann,  J.  P.,  124 
Hesselbacli,  F.  C,  119 
Heterochronia,  218 
Heteroplasia,  218 
Heuermann,  O.,  127 
Heurtelou]),  C.  L.  S.,  108 
Hey,  W.,  89 
Hey's  saw,  776 
HeVfelder,  J.  F.,  122 
Hifton,  J.,  101 
Hip-joint,  amputation  at,  476,  S";2 

dislocations  of,  626 

resection  of,  802 

shot-wounds  of,  474 
Hippocrates,  22 
Hodgen,  J.  T.,  142 
Hodgkin's  disease,  streptococcus  infections 

in,  306 
Hodgson,  J.,  98 
Holder,  J.,  56 
Holscher,  G.  P.,  121 
Home,  Sir  E.,  88 
Homer,  surgery  of,  20 
Home,  J.  von,  59 
Horner,  W.  E.,  137 
Hosjiital  gangrene,  325,  359 
Hospitals,  52 
Hotel  Dieu,  75 
Hot  gangrene,  229 
Hueter,  1".,  125 

Hneter's  method  for  excision  of  elbow,  788 
Humerus,  fracture  of,  584 

resections  of,  788 
Huuczovsky,  J.  N.,  80 


I  lunger,  predisposing  cause  of  infections,  304 
Hunter,  Jolni,  85 

William  (of  Xewport),  131 
Hutchinson,  A.  C,  92 

J.  G,  143 
Hyaline  degeneration,  234 
Hyderaliad  Connnission,  651 
Hydidgen  ]>eroxide,  395 
Hydrophobia,  433 

statistics  of,  435 

treatment  of,  442 
Hyoid  bone,  excision  of,  132 

fracture  of,  572 
Hypersemia,  155 
Hyperplasia,  217 
Hvjiertropliv,  215 
Hyp<.phisia,'229 
Hypostatic  inllamination,  183 
Hysteria,  traumatic,  376 

ILIAC,  common,  ligature  of,  763 
external,  ligature  of,  87,  765 
internal,  ligature  of,  764 
Immunity,  293 
India,  ancient  surgery  of,  24 
Indian  puzzle,  626 
Infection,  677 

atria  of,  279,  308,  339 
bacteria  of,  315 

influence  of  nerve-impulses  on,  296 
Infections,  surgical,  bacteriology  of,  249 
conditions  favoring,  288 
localizations  of,  302 
predisposition  to,  295,  303 
pyogenic  forms,  308 
secondary  and  mixed,   259,   273,  283, 

290,  292,  302,  305,  313 
sources  of,  271,  275 
Inflammation,  145,  311 
clu'onic,  342 
infective,  337 
serous,  169 
svmptoms  of,  335 
treatment  of,  339 
Inhalers,  668 

Innominate  arterv,  ligature  of,  95,  135,  746 
Inoblasts,  223 
Insanity,  confnsional,  following  ansesthesia, 

664 
Instruments,  735 

sterilization  of,  688 
Interscapnlo-thoracic  amputation,  833 
Intestines,  ;uito-infection  from,  306 
bacteria  of,  264 
infections  of,  281 

invasion  of  bacteria  through  mucous  mem- 
brane of,  273,  274,   275,  279,  281, 
282,  298,  321 
obstruction  of,   as  predisposing  cause  of 

infection,  305 
passage  of  bacteria  through  strangulated, 

'  297 
wounds  of,  57 
Intra-uterine  infection  of  the  foetus,  306 
lodococcus  vaginatus  in  the  mouth,  258 
Iodoform,  697,  706 
gauze,  723 


INDEX. 


873 


Ireland,  siirRerv  in,  S9,  99 

Irrigating  solnticms,  703 

Irritable  ulcer,  349 

Irvine,  C.  cle,  68 

Italian  surgery,  history  of,  45,  56,  116 

JAEGER,  M.,  120 
James,  J.  H.,  98 
Jarvis's  adjuster,  610 
Jaw,  lower,  resections  of,  806 

upper,  resections  of,  134,  809 
Jesseuius  a  Jessen,  60 
Jobert,  A.  J.,  UO 
Joint,  false,  536 
Joints,  pyogenic  bacteria  in,  302 

resection  of,  779 

shot-wounds  of,  468 
Jones,  G.  M.,  98 

Jolni,  131 
Jordan,  J.,  98 

Jordan's  method,  amputation  hip-joint,  853 
Josephinum,  117 
Joubert,  L.,  50 
Journals,  surgical,  144 

KARYOMITOSIS,  219 
Keratitis,  oyster-slmcker's,  276 
Kern,  V.  8.  von,  117 
Key,  C.  A.,  93 
Kidney,  ettects  of  ether  on,  662 

elimination  of  bacteria  bv  the,  285,  286 
Kinlock,  K.  A.,  142 
Knee-joint,  am]jntation  at,  134,  848 

disliicatiniis  of,  23,  632 

resection  of,  799 

shot-wounds  of,  476 
Knight,  J.,  141 
Koelpin,  A.  K.,  127 
Krackowizer,  E.,  143 
Krueger,  S.    127 
Kuhl,  K.  A.,  121 

LA  GARDE,  L.  A.,  454,  460 
Lallemand,  C.  P.,  109 
Lallement,  A.  M.,  105 
Lancisi,  G.  M.,  81 
Lanfranc,  40 
Langenbeck,  B.  R.  K.  von,  121 

C.  J.  M.,  118 
Langenbeck' s  method  for  excision  of  elbow, 

788 
Laparotomy  for  shot-wounds,  505 
Lapevronie,  F.  de,  72 
Larrey,  D.  J.,  106 
Larynx,  bacteria  in,  262 

excision  of,  126 
Lassus,  P.,  105 
Latent  microliism,  272 
Laugier,  S.,  UO 
Lautenschlager's  sterilizer,  696 
Lawrence.  W.,  92 
Leander,  R.,  126 
Leber,  F.  von,  79 
Le  Cat,  C.  X.,  73 
Le  Clerc,  G.,  71 
Le  Dran,  H.  P.,  73 
Leech-book,  the,  60 


Leg,  amputation  of,  845 

artificial,  862 

fracture  of,  543 
Le  Gros  Clark  F.,  103 
Leisrink,  II.  W.  P..  126 
Le  Lievre,  E.,  51 
Leprosy.     See  B(iciUii.<  Leprae. 
Leptotiirix  buccali.s,  2.J8 
Leroy  (d'Etiolles),  J.  J.  J.,  108 
Leucocytes,  161 

as  phagocytes,  291,  294 

polynuclear,  242 
Leucocythiemia,  streptococcus  infections  in, 

306 
Leucocytosis,  198 
Levacher,  P.  G.,  74 
Levis' s  hooks,  554 

instrument  for  dislocation  of  fingers,  626 
Lib.,rius,  J.  A.,  128 
Ligature  of  arteries,  32,  50,  742 
Ligatures,  380 
Lightning-stroke,  366 
Lingual  arterv,  ligature  of,  750 
Linhart,  W.  von,  123 
Lipomatosis,  232 
Lisfranc,  J.,  107 
Lister,  J.,  103 
Lister's  nni]iutation,  knee,  850 

metliod  for  excision  of  wrist,  782 

splint,  784 
Liston,  R.,  95 
Litliotomy,  ancient  methods,  34,  38,  47,  61 

suprapubic,  48 
Litbotrity,  108 
Little's   a])paratus  for  fracture   of   patella, 

553 
Littre,  A.,  71 
Liver,  eflects  of  chloroform  on,  665 

elimination  of  bacteria  by,  286 

focal  necroses  in,  286 
Lizars,  J.,  95 
Lloyd,  E.  A.,  97 
Local  iisphyxia,  361 
Locus  minoris  resistentia',  302,  338 
Loeffler,  (i.  P.  P.,  125 
Long,  C.  W.,  138 
Louis,  A.,  72 
Lowdham,  C.  I).,  67 
Liieke,  G.  A.,  125 
Luke,  J.,  100 
Lump-jaw  of  cattle,  332 
Lungs,  bacteria  in,  263,  282 

sbot-wonnds  of,  496 
Lymi)li  in  inflannnation,  159 
Lymphocytes,  163 
Lysoi,  705 

MAAS,  II.,  126 
McClcUan,  G.,  136 
McDowell,  E.,  133 
Mc<;ill,  i:u 

Mclntvre's  splint,  545,  548 
Madui-a,  foot,  334,  352 
Magati,  C,  57 
Maggius,  R,  45 
Malgaigne,  J.  P.,  112 
Malgaigne's  hooks,  553 


874 


INDEX. 


Malignant  a'dema,  bacillus  of.    See  BacUlux 
of  Mitli(jiiniit    (Edema,    caused    by 
livjioilfriiiic  injections,  322 
Malleolus,  internal,  fracture  of,  547 
March,  A.,  139 
Marchetti,  P.  de,  57 
Mareschal,  G.,  70 
Marian  operation,  47 
Marjolin,  J.  N.,  107 
Marshall,  J.,  102 
Masiero,  F.,  58 

Mastitis,  sources  of  bacteria  causing,  287 
Mauchart,  B.  D.,  77 
Maunder,  C.  F.,  103 
Mauquest  de  la  Motte,  G.,  73 
Maury,  F.  F.,  140 
Maxilla.     See  Jaw. 
Meconium,  bacteria  in,  264 
Meekren,  J.  J.  von,  59 
Mery,  J.,  70 

Metacarpal   bones,   disarticulation    of,  821, 
823 
fracture  of,  002 
resection  of,  781 
Metastasis,  401 

Metatarsal  bones,  amputation  through,  835 
dislocation  of,  644 
resection  of,  793 
Methylene  bichloride,  652 
Mexico,  surgery  in,  129 
Micrococcus  gonorrho?*.     See  Gnnoeoccus. 
lanceolatus,  characters  of,  318 
elimination  of,  286,  287 
frequency  of,    in   infections,    309,   311, 

318' 
in  the  intestine,  265 
in  the  lungs,  258,  263 
in  the  middle  ear,  263 
in  the  mouth,  258,  271,  318 
in  the  nose,  261 

pathogenic  eflects,  258,  275,  309,  318 
placental  transmission  of,  307,  308 
variations  in  virulence,  258,   261,   271, 
289,  291,  318 
pneumonite    cruposse.       See    3Iicroeoccus 

LdiiceolafiiK. 
pyogenes  tenuis,  309,  318 
of  sputum    sc|itic,-emia.     See   Micrococcm! 

Jjifiirt'iihitiis. 
tetragenus,  characters  of,  317 
in  the  mouth,  2-58,  260,  261 
in  the  nose,  262 
pathogenic    manifestations,     260,    275, 

309,  311,  318 
septicus,  260,  318 
Middcldorpf,  A.  T.,  123 
Middle  ear,  bacteria  in,  263 
Mikulicz's  method  for  excision  of  ankle,  797 
Miliary  tubercle,  241 
Milk,  bacteria  in  woman's,  270 
bactericidal  pro])erty  of,  271 
elimination  of  bacteria  in,  287 
tubercle  bacilli  in,  287 
Miner,  J.  F.,  143 
IMissiles,  445 

Mitchell,  Weir,   on  nerve-influence  on  in- 
fection, 296 


Mixed  infections,  290 

Moeller,  J.  H.  G.,  128 

Moinichen,  H.  von,  127 

Mojsisovics,  G.,  121 

Mondeville,  Henry  de,  40 

Monnikof,  J.,  80 

Monro,  A.,  85 

Monteggia,  G.  B.,  117 

Monteraayor,  C,  09 

Moore's  dressing  for  fracture  of  clavicle, 
581 

Morand,  S.  F.,  72 

Morgan,  C.  de,  101 
J.,  98 

Morstede,  J.,  61 

Morus,  H.,  64 

Mosetig-Moorhof's  method  for  excision  of 
elbow,  788 

Mott,  v.,  134 

Mouth,  bacteria  of,  2-57 
disinfection  of,  723 

Mucoid  degeneration,  233 

Mucous  membranes,  bacteria  of,  255 

elimination  of  bacteria  through,  284 
penetrabilitv  of,  bv  bacteria,  279,  280, 

281,  282 
possibility  of  infection  of,  257,  273 

Mutter,  T.  I).",  136 

Mummification,  228 

Mummy,  55 

Muralt,'  J.  von,  60 

Mursinna,  (.'.  L.,  118 

Muscles,  regeneration  of,  224 

Muscles,  gunshot  wounds  of,  458 

M-usitanus,  ('.,  58 

Mussev,  K.  I).,  137 

Muy.s,'j.,  59 

Mycetoma.     See  Bladara  Foot. 

Mvddvai,  physicians  of,  61 

Mynors,  K.,  89 

NAGUMOWITSCH,  L.,  128 
Nancrede  on  symptoms  and  treatment 

of  inflanmiation,  etc.,  335 
Nannoni,  A.  and  L.,  81 
Naplitluduic,  706 
Narcosis  as  predisposing  cause  of  infections, 

304 
Nasal  secretion,   bactericidal   property   of, 

262 
Neck,  shot-wounds  of,  489 
Necrogenic  warts,  276 
Necrosis,  165,  225 

a  predisposing  cause  of  infection,  301 
Neill,  J.,  143 
Nelaton,  A.,  113 
N^laton's  line,  567 

metliod  for  excision  of  elbow,  788 
probe,  451 
Nelson,  R.,  142 
Nephrectomy,  125 
Nephrotomy,  21 
Nerve-impulses,   influence  of,  on  infection, 

296 
Nerves,  regeneration  of,  225 
Netherlands,  surgery  in,  58,  80,  115 
Neuber's  tubes,  703 


INDEX. 


875 


Neurasthenia,  376 

Neiirectomv,  87 

Neuritis,  multiple  peripheral,  39"2 

Neuropathic  atrophy,  231 

Neurotomy,  SO 

Nitrous  oxide,  647,  664 

N  orris,  tr.  W.,  136 

Norsiui,  the,  47 

Nose,  bacteria  of,  261 

tubercle  bacilli  in,  262 
Nott,  J.  C,  143 
Nuclein,  bactericidal  pi'opert)'  of,  294 

OBESITY,  ertect  of,  in  an*sthesia,  656 
Obligatory  parasites,  2/8 
Occipital  artery,  ligature  of,  752 
Oi^dema,  IGO 

glottidis,  573 

influence  of,  on  infection,  296 
O'llalloran,  8.,  90 
Oidiuni  albicans  in  the  vagina,  269 
( )il  of  ]iiippies,  49 
Olecranon  process,  fracture  of,  601 
OUier's  method  for  excision  of  elbow,  788 
of  hip-joint,  803 
of  wrist,  784 
Onsenoort,  A.  G.  von,  116 
Operating-rooms,  707,  735 
Operating-tal)lc,  708 
Operations,  ]ircparations  fur,  733 

a-septic,  710 
Operative  surgery,  729 
Oribasius,  31 
Ormsby's  inhaler,  669 
Os  calcis.     See  Vnlcnneum. 
Osteoblasts,  223 

Osteomvelitis,   bacteria   causing,    282,   309, 
311,  312,  321 

experimental  production  of,  303 
Osteoplastic  amputation  of  ankle-joint,  844 

excision  of  ankle,  797 

excision  of  elbow,  788 
Ostitis  albuminosa,  bacteria  causing,  312 
Otis,  G.  A.,  142 
Otitis  media,  bacteria  in,  263 
Oval  method  in  amputation  of  fingers,  819 
Ovariotomy,  72,  124.  133,  134 
Oystcr-sliHi'ker's  keratitis,  276 
Oza-na,  bacillus  of,  262 

PACKING,  71§ 
Pain  in  inflammation,  158 
Palfvn,  J.,  80 
Palletta,  G.  B.,  116 
Palmar  arch,  ligature  of,  761 
Pancoast,  J.,  140 
Papyrus  Ebei-s,  18 
Paquelin's  cautery,  742 
Paracelsus,  54 
Parasites,  obligatorv,  278 
Pare,  A.,  49 
Park,  H.,  88 
Parker,  W.,  135 
Paronychia,  351 

Pasteur's  treatment  for  rabies,  442 
Patella,  dislocatiims  of,  635 
excision  of,  801 


Patella,  fracture  of,  550 

wiring  of,  556 
Patliologv,  surgical,  145 
Panl,  H.'J.,  124 
Pauhis  -Egineta,  31 
Pelletan,  P.  J.,  H)5 
Pelvis,  fracture  of,  570 
Pental,  653 
Pepiniere,  the,  78 
Percv,  P.  F.,  106 
Periosteal  flaps,  816 
Perioslcotonics,  775 
Periostitis  following  typhoid  fever,  321 

all>nminosa,  bacteria  causing,  312 
Peritonitis,  bacteria  in  perforative,  265,  274 
Pernio,  354 

Peroxide  of  hydrogen,  706 
Petit,  Jacques,  75 

J.  L.,  72 
Petrecjuin,  J.  P.  E.,  115 
Pfolzprundt,  M.,  53 
Phagocytic  theory,  166,  294 
Phalanges,  dislocations  of,  626,  644 

fracture  of,  540,  603 

resection  of,  780,  792 

of  foot,  amputation  of,  834 
Pharynx,  bacteria  of,  257 
Phelps,  C.,  on  wiring  the  patella,  556 
Phioravanti,  L.,  51 

Phlegmons,  bacteria  causing,  309,  310,  311 
Phloridzin,  increases  susceptibility  to  gland- 
ers, 305 
Physick,  P.  S.,  132 
Physick's  elbow-splint,  589 
Pigmentation,  221,  237 
Pigrav,  P.,  52 
Pirogotr,  N.  I.,  128 
Pirogofl's  amputation,  844 
Pitcairn   A.,  83 
Pitha,  F.  von,  122 
Placental  transmission  of  micro-organisms, 

306 
Plainer,  J.  Z.,  77 

Pneumococcus.    See  Micrococcus  Lanceolatus. 
Poland,  A.,  102 
Poisons,  animal,  408 
Pope,  C,  141 

Popliteal  artery,  ligature  of,  7ti9 
Porta,  L.,  117' 
Portals   of    entry   of    bacteria    in    surgical 

infections,  279 
Porter,  W.  H.,  99 
Post,  A.  C,  136 

W.,  132 
Potassium  permanganate,  706 
Pott,  P.,  85 
Pott's  fracture,  549 
Pravaz,  C.  G.,  Ill 
Predisposition,  292,  295,  303 
Price,  P.  C,  102 
Probe,  Girdner's,  451 

Nelaton's.  451 
Prognosis  in  operations,  730 
Proteids,  defensive,  294 
Proteus.     See  BnciUus  Proteus. 
Pseudarthrosis,  536 
Pseudo-diphtheria  bacillus,  257,  260 


876 


INDEX. 


Pseudo-gonococci,  206,  2G7,  208,  319 

I'seiul()-iiiHueiiz;i  liacillus  of  I'i'eitier,  203 

I'uliic  liniif,  I'nicliiii'  (if,  571 

I'lidic  arU'i-v,  intunial,  ligature  of,  V(>o 

I'lK'ipural  infection,  bacteria  of,  208,  274 

I'lippies,  oil  of,  49 

I'lirmaiiii,  M.  <  1.,  00 

I'liruk-iit  intlanimatloii,  171 

Pus,  172 

blue,  253,  320 

micro-organisms  of,  176,  308 
Pyfcmia,  249,  273,  2S3,  314,  314 

crviitugenetic,  283,  298 
Pyogenic  bacteria,  170,  179,  289,  308 

cocci,  308.     See  also  Staphylococcus  Pyo/j- 
enes  and  Streptococcus  Pi/ogenes. 

absorption  of,  284,  300 

associations  of,  291 

efiects  of,  290,  302,  311 

elimination  of,  285 

predisposition  to,  general,  303,  306,  318 
local,  290,  298,  301,  302,  312 

virulence  of,  270,  271,  273, 275,  283,  289, 
292,  296,  312 

in  air,  277 

in  bile,  263 

in  blood,  314 

on  external  objects,  275,  278 

in  Hies'  excrement,  276 

in  tlie  fo'tns,  307 

on  tlie  liair,  254,  278 

in  the  lungs,  282 

in  milk,  270 

in  the  mouth,  259 

in  the  nose,  201 

on  the  skin,  252 

in  the  soil,  270 

in  the  stomach  and  intestines,  265,  298 

in  the  urethra,  207 

in  the  vagina,  208 
membrane,  174 
Pyosepticfemia,  404 
Pyrogenic  substances,  203 


Q 


UERfETANUS,  51 
Qucsnay,  F. ,  70 


RABIES,  433 
Kadial  artery,  ligature  of,  759 
Eadius,  dislocation  of,  022 

fracture  of,  594 

resection  of,  785 
Randolph,  J.,  143 
Ranke,  H.  K.,  116 
Rau,  J.  J.,  80 
Ravaton,  H.,  74 
Rarotb,  F.  W.  T.,  124 
Raynaud's  disease,  361 
Read,  A.,  04 
Rectum,  cancer  of,  01 
Reef-knot,  740 
Regeneration,  193,  219 
Repair,  190 
Resections,  773 
Resolution,  191,  330 
Respiration,  artificial,  075 
Respiratory  passages,  bacteria  of,  201 


Key  her,  ('.,  129 

Rhinitis   fibrinosa,   diphtheria   bacillus  in, 

202 
Rhinoplasty,  4() 

Rhinoscleroma,  bacillus  of,  202,  320 
Ribs,  dislocation  of,  013 

fracture  of,  573 

resections  of,  805 
Richard,  F.  A.,  115 
Richerand,  B.  A.,  106 
Richet,  L.  A.,  114 
Richter,  A.  G.,  79 
Riding  endjoli,  212 
Rigidity,  traumatic,  482 
RizzoU;  F.,  117 
Rklizkv,  I.,  129 
Rochard,  J.,  105 
Rodgers,  J.  K.,  135 
Roger  of  Parma,  39 
Roland,  39 

Romanes,  John  de,  47 
Roonhuvsen,  H.  van,  59 
Roux,  J.,  112 

P.  J.,  106 
Roux's  amputation  at  ankle-joint,  844 
Rubber  drainage-tubes,  703 
Rudtorfier,  F.  X.,  118 
Russell,  J.,  94 
Russia,  surgery  in,  128 
Rust,  J.  N.,  118 
Ruvsch,  F.,  80 
Ryff,  W.  H.,  54 

SABATIER,  R.  B.,  75 
Salire-wounds,  512 
St.  Bartholomew's  Hosjiital,  81 
St.  C'6me,  College  of,  72 
St.  Thomas's  Hospital,  81 
Salernum,  School  of,  39 
Salicylic  acid,  705 
Saliva,  germicidal  power  of,  260 
Salivary  glands  and  ducts,  bacteria  in,  261 

elimination  of  bacteria  by,  288 
Salter's  swing,  548 
Samuel,  150,'  160 
Sanctus  Barolitanus,  M.,  46 
Sands,  H.  B.,  139 
Sanson,  L.  J.,  107 
Santesson,  C.  G.,  128 
Saprsemia,  383,  390 
Saprophytes,  278 
Sarcoma  of  bone,  525 
Saviard,  B.,  71 
Saw.s,  770 
Say  re's  method  for  excision  of  hip-joint,  803 

for  fracture  of  clavicle,  579 
Scalds,  362 
Scalpels,  774 
Scapula,  dislocation  of,  617 

fracture  of,  582 

resections  of,  790 

and  arm,  amputation  of,  833 
Scarpa,  A.,  110 
Scarpa's  triangle,  707 
Schede's  method,  494,  526 
Schillbach,  E.  L.,  124 
Schimmelbusch's  boiler,  6S9 


INDEX. 


877 


Schiramelbusch's  sterilizer,  094 
Sehlichtinsj,  J.  D.,  «0 
Sc'limatis,  L.,  4o 
Schmidt,  J.,  60 
Sclimuclcer,  J.  L.,  78 
Schuh,  F.,  122 

Sciatic  arterv,  ligature  of,  765 
Scoiitettin,  R.  II.  J.,  112 
Scott's  splint,  595 
Sciiltetus,  J.,  59 

Secretions,  bactericidal  properties  of,   256, 
260,  2()2,  264,  265,  267,  269,  271 

elimination  of  bacteria  in  the,  284 
Sedillot,  C.  E.,  115 

Semilunar  cartilages,  dislocations  of,  634 
Sei)tic:emia,  175,  249,  314,  383 

crvptogenetic,  283,  298 

bacteria,  due  to  exposed  mucous  surfaces, 
273,  275,  283 

due  to  streptococcus  pyogenes,  283,  306, 
313,  314 

secondary,  273,  275,  283,  292,  300,  308, 
313,  314 

terminal,  300 
Septico-pya^mia,  cryptogenetic,  283,  298 
Serous  iuHammation,  109 
Serpent-bites,  410 
Serratns  magnus,  paralysis  of,  617 
Serre,  M.,  109 
Serum-therapy,  295,  328 
Seyerinus,  M.  H.,  57 
Sharp,  S.,  84 

Sherrington  on  elimination  of  bacteria,  285 
Shippeu,  W.,  132 
Shock,  454,  858 
Shoulder-joint,  amputation  at,  829 

dislocation  of,  017 

resection  of,  790 

shot-wounds  of,  471 
Shrady's  saw,  770 
Siebold,  C.  C.  yon,  79 
Sigault,  J.  R.,  76 
Silyer-fork  fracture,  595 
Simon,  C,  J.  F.  L.  G.,  125 
Sims,  J.  M.,  139 
Skey,  F.  C,  101 
Skev's   method  in  dislocation  of  shoulder, 

020 
Skin,  bacteria  of,  250,  272 

cleansing  of,  251,  27'J,  085 

normal  defences  against  bacteria,  279 

penetrability  to  bacteria,  252,  280 

persistence    of   corrosiye    sublimate    on, 
252 

white  coccus  of,  251,  272,  292 
Sloughs,  173 
Slumbering  cells,  164 
Smegma  bacillus,  254,  206,  329 
Smith,  II.  H.,  140 

(II.  H. ),  method  in  dislocations  of  shoul- 
der, 621 
.splint,  539 

N.,  134 

R.  \V.,  100 

Stephen,  method  of  amputation  at  knee- 
joint,  849 
on  operatiye  surgery,  729 


Smith's  anterior  splint,  545,  560 
Societies,  surgical,  144 
Socin's  paste,  700 
Soden,  J.  S.,  98 
Soil,  bacteria  in,  253,  276 
Solingen,  C,  59 
Sorauus,  30 
Souberbielle,  J.,  108 

Sources  of  bacteria  in  surgical  infections,  271 
South,  J.  F.,  97 
Southam,  G.,  99 
Spain,  history  of  surgery  in,  68 
Spanish  windlass,  610,  722 
Spa.smotoxin,  320 

Spence's  method  of  amputation  at  shoulder- 
joint,  830 
Sphacelus,  229 
Spider-bites,  409 
Spigelius,  57 

Spine,  shot-wounds  of,  492 
Spirilla  in  epithelial  cells  of  dog's  stomacli, 
272 
in  the  mouth,  258 
in  the  nose,  202 
Spirillum  sputigcmun,  2.58 
Spirochiete  dentium,  258 
Spleen,  excision  of,  58 
Sponges,  698 
Spore-forming  bacteria,  list  of  pathogenic, 

278" 
Stanley,  E.,  98 
Staphylococcus,  177 

cereus  albus,  characters  of,  310 

pathogenic  characters  of,  309,  310, 
316 
flayus,  309,  310 
epidermidis  albus,  in  abscesses  and  other 
inHammatious,  310 
in  aseptic  wounds,  251,  272,  292 
in  blood,  252,  314 
characters  of,  251,  315 
cause  of  stitch-abscesses,  252,  272 
infection   fayored    by   drainage-tube 

and  necrotic  tissue,  251,  272,  299 
in  .sweat,  252,  288 
in  women's  milk,  270,  287 
pyogenes  albus,  characters  of,  315 
frequency  of,  310 
yirulenceof,  271,  310,  315 
in  aseptic  wounds,  272,  314 
in  conjunctiva,  250 
in  the  mouth,  258,  260 
in  the  nose,  202 
in  woman's  milk,  270,  287 

aureus,  in  asc|itic  wounds,  292 
in  blood-dots  in  wounds,  299 
characters  of,  315 
in  the  conjunctiya,  256 
elimination  of,  285,  286,  287,  288 
freciuency  of,  310 
in  the  milk,  270,  287 
in  the  mouth,  259 
in  the  nose,  201 
in  osteomyeliti.s,  303,  313 
pathogenic  ettects,  252,  280,  303,  309, 

311 
on  the  skin, 252 


878 


IMiEX. 


Staphylococcus      jivogenes    aureus    in    the 
sweat,  28S 
iu  tlie  uretiira,  2(5^,  207 
in  tlie  vagina,  2(i9 
virulence  of,  2S9 
citreus,  characters  of,  315 

pathogenic  eflects,  309,  311,  315 
Steam  sterilizers,  093 
Sterilization,  082,  ()93 
Sternum,  dislocation  of,  014 
fracture  of,  570 
resections  of,  805 
Stilling,  B.,  124 
Stings,  408 

Stitch-abscesses,  252,  272 
Stomach,  bacteria  in,  203 

resection  of,  120 
Streptococcus,  177 
brevis,  258,  317 
conglomeratus,  317 
erysipelatos,  ol(i 

antagonistic  to  infection  with  anthrax, 
291 
longus,  258,  317 

pyogenes,  antagonisms  of,  291.     See  also 
Pi/oqenic   Cocri. 
associations  of,  259,  291,  292,  324 
characters  of,  316 
elimination  of,  280,  287 
frequency  of,  310,  311 
pathogenic  eflects  of,  259,  275,  289,  292, 

300,  310,  313,  310,  324 
varieties  of,  258,  317 
virulence  of,  259,  271,  277,  289,  291, 

313,  310,  317,  325 
in  the  air,  277 
in  the  bile,  265,  286 
in  the  blood,  314 
in  the  conjunctiva,  256 
in  tlie  intestine,  205 
in  the  lungs,  259,  263 
in  the  middle  ear,  263 
in  the  mouth,  258 
in  the  nose,  261 
in  secondary  and  mixed  infections,  259, 

275,  283,  292,  313 
in  septicaemia,  300,  313,  314 
on  the  skin,  253 
in  the  urethra,  207 
in  the  vagina,  269 
in  wounds,  300,  313,  324 
Stromeyer,  G.  F.  L.,  122 
Stromeyer's  cushion,  591 
Styptic,  54 
Subastragaloid  amputations,  841 

dislocation,  642 
Suliclavian  artery,  ligature  of,  746,  755 
Subcoracoid  dislocation,  617 
Subperiosteal  exsection  of  elbow,  787 
Sue,  J.  J.,  74 
Sulpho-naphthol,  396 
Sunburn,  305 
Suppuration,  172,  182 

accompanying  or  following  tvphoid  fever, 

32i 
bacteria  of,  308 
bactericidal  intluence  of,  297 


Supi)uration,     local    causes    favoring,    291, 
290,  301,  303,  313 

from  sterile  chemical  substances,  292 

in  subcutaneous  fractures,  272,  302 
Su]ira-condylciid  fracture  of  humerus,  585 
Supra-mallcolar  amputation,  845 
Surgeon's  knot,  740 
Surgery,  conservative,  96 

history  of,  17 

oijerative,  729 
Sm-giial  infections.    See  Infections,  Surgieal. 

jiHuijals  and  societies,  144 
Su.sccplibility,  293 
Susrula,  24 
Sutures,  98,  700 
Sweat,  elimination  of  bacteria  by,  288 

staphylococcus  epidermidis  albus  in,  252, 
"  288 
Sweden,  surgery  in,  127 
Swelling  in  inflammation,  159,  107 
Syme,  J.,  90 
Syme'.s  amputation,  843 
Sympathetic  inflammation,  186 

powder,  68 
Symptomatic  anthrax,  bacillus  of,  292,  304, 

307 
Syncope,  859 
Syphilis,  44 

Syringes,  disinfection  of,  090 
Sz}'manowsky,  J.,  129 

TASSONI,  G.,  81 
T.agliacotius,  G.,  40 
Talmu<l,  surgery  of,  19 
Tamjionade,  697 
Tarsal  bones,  dislocation  of,  643 
fracture  of,  540 
resection  of,  794 
Tarso-metatarsal    articulation,    amputation 

at,  838 
Tarsn-s,  synovial  membranes  of,  794 
Tassin,  L.,  58 
Taylor,  J.,  84 
Teale,  T.  P.,  98 
Teale's  amputation,  815 
Tecvan,  W.  F.,  103 
Tcevan's  law,  482 
Telepliouic  ])robe,  451 
Tem]ioral  artery,  ligature  of,  752 
Tenaculum,  739 
Teno-syuovitis,  351 
Tenotomy  in  compound  fractures,  526 
Tetauiu,  32() 
Tetanotoxin,  326 
Tetanus,  426 

autitoxiue  of,  395,  328,  431 

bacillus  of     See  Baeillus  Tetani. 

after  fracture,  532 

ptomaines  of,  326 

toxin  of,  327 
Tetany,  430 
Texto'r,  K.  von,  120 
Thaden,  A.  G.  J.  von,  125 
Theden,  J.  C.  A.,  78 
Tliermo-cantery,  742 
Thiersch's  solution,  39-5,  705 
Thigh,  amputation  in,  850 


INDEX. 


879 


Thomson,  J.,  94 
Thrombosis,  205,  40() 
Thulstrup,  M.  A.,  128 
Thumb,  amjjutation  of,  821 

disloraticin  of,  025 
Tliymol,  70() 
Thyroid  artery,  inferior,  ligature  of,  754 

superior,  ligature  of,  SS,  749 
Tibia,  resections  of,  797 

dislocations  of  liead  of,  633 

fracture  of,  546 
Tibial  artery,  anterior,  ligature  of,  771 

posterior,  ligature  of,  770 
Tilanus,  C.  B.,  il(j 
Titsingh,  A.,  SO 
Toes,  amputation  of,  834 
Tolet,  P.,  51 

Tongue,  shot-wounds  of,  488 
Tonsil,  as  atrium  of  infection,  259,  279 
Torsion  of  arteries,  740 
Tourniquet,  t)7,  71,  739 

Bloxarn's  dislocation,  611 
Toxalburain  «(  diplitheria,  323 

of  tetanus,  327 
Toxic  prodticts  of  bacteria,   289,   291,  314, 

323,  327 
Toxines,  289 

Transplantation  of  tissue,  220 
Traumatic  delirium,  374 

fever,  415 

rigiditv,  482 
Travers,"B.,  94 
Trelat,  U.,  114 

Trelat's  method  for  fracture  of  patella,  554 
Trephining,  57 

prehistoric,  18 
Tripier's  amputation,  841 
Trochanter  major,  fracture  of,  565 
Trophic  inflammation,  185 
Tuberculosis,  239 

bacillus  of.     See  Bacillus  Tuhercxdosis. 

congenital,  247 

infectiuns  secondary  to,  292,  302,  313 

inheritance  of,  282,  307 

of    internal    parts   without   demonstrable 
atrium  morbi,  282 

intestinal,  experiments  concerning,  282 
Tufiiell,  T.  J.,  100 
Tumors,    treatment    with    erysipelas    virus, 

423 
Twitchell,  A.,  134 
Tympanic  cavity,  bacteria  in,  263 
Typhoid  fever,  ostenniyelitis  and  periostitis 
following,  321 
suppurations  accompanving  or  follow- 
ing, 321 
surgical   infections   secondary  to,   273, 
275,  283,  292,  3l5,  321 

ULCERATION,  187,  343 
Ulcers,  346 
Ulna,  dislocations  of,  622 
fracture  of,  600 
resection  of,  785 
Ulnar  artery,  ligature  of,  760 
I'nited  States,  surgery  in,  130 
Ununited  fracture,  536 


Urethra,  bacteria  in,  266 
disinfection  of,  727 

Urine,  bacteria  in,  266 
bactericidal  power  of,  267 
elimination  of  bacteria  in  the,  285 
of  tetanus  toxin  in  the,  327 

VA(H\A,  bacteria  in,  267 
disinfection  of,  727 
Vaginal  bacilli,  268,  269 

secretions,  bactericidal  powers  of,  269 
Valsalva,  A.  M.,  81 
Vauguion,  de  la,  58 
Veins,  throniljosis  of,  213 
Velpeau,  A.  A.L.  M.,  109 
Velpeau' s  dressing  for  fracture  of  clavicle, 

581 
Venoms,  408 

Verneuil's  subastragaloid  amputation,  842 
Vertebne,  resections  of,  805 
Vertebral  artery,  ligature  of,  753 
Vevras,  J.,  51 
Vicarv,  T.,  62 

VidaUdeCassisX  A.  T.,  lU 
Vigo,  John  de,  44 
Virchow  on  intiammation,  164 
Virulence  of  infecting  bacteria,   289,   291, 

312 
Vogt,  P.  F.  I.,  126 
Volkmann,  R.  von,  126 
Volkmaun's   operation    for    psoudarthrosis, 

639 

WAtiNER,  C.  E.  A.,  123 
Waltber,  P.  F.,  von,  118 

"^Vard,  J.,  67 

Wardrop,  J.,  92 

Warner,  J.,  88 

Warren,  .).,  132 
J.  (_;.,  132 

on  traumatic  fever,  erysipelas,  and  teta- 
nus, 415 

Warts,  necrogenie,  276 

Water,  sterilization  of,  703 

WatS(m,  J.,  136 

Wattmann,  J.  von,  118 

\\'axy  tlegeneration,  227 

Weapon-salve,  68 

Welch,  ^V.  II.,  bacteriology  of  surgical  in- 
fections, 249 

Wernlier,  A.,  120 

White,  C,  89 

White  gangrene,  360 

William  of  Salicet,  40 

Willv  Mever's  .sterilizer,  695 

Wilms,  125 

Wiseman,  R.,  66 

Wood,  ii.   B.,  experiments  on  ansesthesia, 
661      . 
H.  C,  on  anaesthesia,  045 
J.  R.,  139 

Wood's  method  in  dislocations  of  shoulder, 
620 

Woodall,  J.,  65 

Wound-fever,  56,  415 

Wound- infection,  271 

\\'ounds,  366 


880 


INDEX. 


'Wounds,   absorption  of  bacteria  i'roiii,  284, 

297,  300 
air-inlVrtion  of,  276 

antiseptic  treatment  of,  experiments  con- 
cerning, 300 

aseptic  treatment  of,  experiments  concern- 
ing, 301 

bacteria  in  infected,  249,  251,  253,  272, 
273,  275,  284,  292,  298,  300,  310, 
313,  324,  325 

blood-clot,  healing  of,  299 

conditions  favoring  infection  of,  252,  295, 

298,  303 
contact,  infection  of,  275 
diphtlieria  of,  324 
disinfection  of,  253,  284,  300 
drainage  of,  369 

hospital  gangrene  of,  325 

of  mucous  membranes,   bacteria  in,  259, 

273 
necrotic  inflammation  of,  324 
sources  of  bacteria  in  infected,  271,  272,275 
treatment  of,  715,  721 
arrow-,  513 

aseptic,  bacteria  in,  251,  272,  292 
bavonet-,  512 
gunshot,  49,  53,  276,  445 


Wounds,  jioisoned,  372,  407 

sal>re-,  512 
Wrist,  shot-wounds  of,  474 
\\'rist-(lrni),  590 
Wrist-joint,  amputation  at,  82G 

dislocations  of,  623 

resection  of,  782 
Wry-neck,  67 
Wurtz,  F.,  55 
Wutzer,  V.  W.,  120 

Wyetli's  bloodless  method  of  amputation  of 
hip-joint,  855 

saw,  778 
Wyssokowitsch  on   cliiriination  of  bacteria, 
285 

yEKOSIS  BACILLUS.  257 

YONGE,  J.,  66 
Yperman,  J.,  40 

ZANG,  C.  B.,  118 
Zeis,  E.,  124 
Zenker's  degeneration,  227 
Zoonotic  erysipeloid  from  crabs  and  other 
shell-tish,  276 


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